HESI Adaptive Exam Latest Updated 2024
Which action performed by the nursing student during the chest examination of a client needs
correction? - ANSWER-Placing the stethoscope over bony prominences
During chest examination in a healthy client, the APN percusses and hears a low-pitched sound over the
lungs. Which sound should the nurse document in the medical record? - ANSWER-Resonance
The nurse places a pulse oximetry probe on the finger and toe of a client with a respiratory disorder to
determine the oxygen saturation of hemoglobin (SpO2). Which other parameter can be determined
using this technique? - ANSWER-Arterial oxygen saturation
The nurse finds that a client with a urinary disorder has very pale-yellow-colored urine. What is the
significance of this abnormal finding? - ANSWER-It indicates dilute urine.
What should the nurse do when the defining characteristics of assessment data for a client can apply to
more than one diagnosis? Select all that apply. - ANSWER-1) gather more information
2) identify related factors
3) review all defining characteristics
The nurse is assessing a client following abdominal surgery. Which assessment findings should the nurse
use to form a data cluster? Select all that apply. - ANSWER-1) the patient reports pain with movement
2) the patient has pain over the surgical area
3) the client rates the pain as 8 on the scale
Which related factor is appropriate for a nursing diagnosis? - ANSWER-Trauma of incision
Which action performed by the nursing student during the chest examination of a client needs
correction? - ANSWER-Placing the stethoscope over bony prominences
During chest examination in a healthy client, the APN percusses and hears a low-pitched sound over the
lungs. Which sound should the nurse document in the medical record? - ANSWER-Resonance
The nurse places a pulse oximetry probe on the finger and toe of a client with a respiratory disorder to
determine the oxygen saturation of hemoglobin (SpO2). Which other parameter can be determined
using this technique? - ANSWER-Arterial oxygen saturation
The nurse finds that a client with a urinary disorder has very pale-yellow-colored urine. What is the
significance of this abnormal finding? - ANSWER-It indicates dilute urine.
What should the nurse do when the defining characteristics of assessment data for a client can apply to
more than one diagnosis? Select all that apply. - ANSWER-1) gather more information
2) identify related factors
3) review all defining characteristics
The nurse is assessing a client following abdominal surgery. Which assessment findings should the nurse
use to form a data cluster? Select all that apply. - ANSWER-1) the patient reports pain with movement
2) the patient has pain over the surgical area
3) the client rates the pain as 8 on the scale
Which related factor is appropriate for a nursing diagnosis? - ANSWER-Trauma of incision
