HESI HEALTH ASSESSMENT EXAM NEXT
GENERATION (NGN LATEST 2025 ACTUAL
EXAM WITH COMPLETE EXAM QUESTIONS
AND CORRECT DETAILED ANSWERS (100%
VERIFIED ANSWERS) |ALREADY GRADED
A+| ||PROFESSOR VERIFIED||
Section 1: Foundational Assessment & Vital Signs (Q1-20)
1. Q: A nurse is preparing to assess a new client. Which action should the nurse
perform first?
A. Review the client’s medical record.
B. Introduce themselves and explain the purpose of the assessment.
C. Gather all necessary equipment.
D. Perform hand hygiene.
A: B. Introduce themselves and explain the purpose of the assessment. The first step is always
to establish the nurse-client relationship, ensure consent, and reduce anxiety.
2. Q: When percussing over a dense organ like the liver, the expected sound is:
A. Tympany.
B. Resonance.
C. Dullness.
D. Hyperresonance.
A: C. Dullness. Dullness is heard over solid organs (liver, spleen, heart) or fluid.
3. Q: A client’s blood pressure reading is 152/94 mmHg. How should the nurse
categorize this?
A. Prehypertension
B. Stage 1 Hypertension
C. Stage 2 Hypertension
D. Hypertensive Crisis
A: B. Stage 1 Hypertension. According to AHA guidelines, Stage 1 is SBP 130-139 or DBP 80-89.
,However, a single reading is not diagnostic; it requires an average of two or more readings on
separate occasions.
4. Q: The nurse palpates a radial pulse that is irregular in rhythm and weak in strength.
What is the priority action?
A. Document the finding.
B. Assess the apical pulse for a full minute.
C. Check the pulse in the other arm.
D. Ask the client if they feel dizzy.
A: B. Assess the apical pulse for a full minute. An irregular pulse requires a full minute apical
assessment for accuracy to detect a pulse deficit.
5. Q: What is the normal range for oxygen saturation (SpO2) in a healthy adult?
A. 75-85%
B. 88-92%
C. 95-100%
D. 100% only
A: C. 95-100%. Values below 95% often require investigation, though targets may be lower for
clients with chronic lung conditions like COPD.
6. Q: To accurately assess a client’s respiratory rate, the nurse should:
A. Inform the client they are counting their breaths.
B. Count for 15 seconds and multiply by 4, after pulse assessment.
C. Keep fingers on the radial pulse while observing the chest rise.
D. Ask the client to breathe deeply.
A: C. Keep fingers on the radial pulse while observing the chest rise. This prevents the client
from altering their breathing pattern (conscious control).
7. Q: A client has a temperature of 38.8°C (101.8°F). Which accompanying finding
requires immediate intervention?
A. Flushed, warm skin.
B. Heart rate of 102 bpm.
C. Altered mental status/confusion.
D. Complaints of muscle aches.
A: C. Altered mental status/confusion. This is a sign of possible severe infection or sepsis and
indicates a worsening condition.
8. Q: The difference between a client’s systolic and diastolic blood pressure is called:
A. Pulse pressure.
B. Mean arterial pressure (MAP).
,C. Auscultatory gap.
D. Orthostatic pressure.
A: A. Pulse pressure. Normal is about 40 mmHg. A narrow or wide pulse pressure can indicate
specific pathologies.
9. Q: When assessing for orthostatic hypotension, a positive finding is indicated by:
A. An increase in heart rate of 10 bpm.
B. A drop in systolic BP of 20 mmHg or more, or a drop in diastolic BP of 10 mmHg or more.
C. The client feeling lightheaded immediately upon standing.
D. All of the above.
A: B. A drop in systolic BP of 20 mmHg or more, or a drop in diastolic BP of 10 mmHg or
more. While symptoms (C) are important, the diagnosis is based on these specific BP criteria.
10. Q: A tympanic thermometer is contraindicated for which client?
A. A 4-year-old with an ear infection.
B. A 40-year-old who is asleep.
C. A 70-year-old with hypertension.
D. It is never contraindicated.
A: A. A 4-year-old with an ear infection. Otitis media or cerumen impaction can distort the
reading and cause discomfort.
(Q11-20 continue with topics like pain assessment scales, developmental considerations for
vitals, MAP calculation, etc.)
Section 2: Head-to-Toe Physical Assessment (Q21-50)
21. Q: During a head assessment, the nurse notes the client’s sclera has a yellow tinge.
This should be documented as:
A. Cyanosis.
B. Jaundice.
C. Pallor.
D. Ecchymosis.
A: B. Jaundice. Yellowing of the sclera (icterus) indicates hyperbilirubinemia.
22. Q: The nurse is testing cranial nerve VIII. Which action is correct?
A. Ask the client to stick out their tongue.
B. Perform the whisper test or use a tuning fork (Rinne/Weber).
C. Shine a light into the client’s pupil.
D. Ask the client to smile and show their teeth.
A: B. Perform the whisper test or use a tuning fork. Cranial nerve VIII is the
Acoustic/Vestibulocochlear nerve, responsible for hearing and balance.
, 23. Q: A client has diminished breath sounds in the left lower lobe posteriorly. To further
assess, the nurse should:
A. Ask the client to cough, then listen again.
B. Percuss the area for dullness.
C. Have the client lean forward and listen.
D. Both A and B.
A: D. Both A and B. Coughing may clear temporary atelectasis. Percussion for dullness would
indicate consolidation (e.g., pneumonia) or effusion, which could explain diminished sounds.
24. Q: When auscultating heart sounds, the "lub" (S1) sound is best heard at the:
A. Apex of the heart (mitral area).
B. 2nd right intercostal space (aortic area).
C. 2nd left intercostal space (pulmonic area).
D. Lower left sternal border (tricuspid area).
A: A. Apex of the heart (mitral area). S1, caused by closure of the AV valves (mitral & tricuspid),
is loudest at the apex.
25. Q: The nurse palpates a pulsating mass in the client’s abdomen. What is
the priority action?
A. Measure the abdominal girth.
B. Auscultate the area for a bruit.
C. Notify the provider immediately.
D. Ask about a history of constipation.
A: C. Notify the provider immediately. A pulsating mass, especially in the epigastric area, is a
potential sign of an abdominal aortic aneurysm (AAA), which is a medical emergency.
26. Q: Capillary refill time is assessed to evaluate:
A. Peripheral perfusion and cardiac output.
B. Neurological function.
C. Nutritional status.
D. Hydration status only.
A: A. Peripheral perfusion and cardiac output. Normal refill is <2-3 seconds. Prolonged refill
indicates poor perfusion.
27. Q: To assess for pitting edema, the nurse presses firmly against the client’s ankle for
5 seconds. A deep pit (8mm) that lasts for over 2 minutes is graded as:
A. 1+ edema.
B. 2+ edema.
C. 3+ edema.
GENERATION (NGN LATEST 2025 ACTUAL
EXAM WITH COMPLETE EXAM QUESTIONS
AND CORRECT DETAILED ANSWERS (100%
VERIFIED ANSWERS) |ALREADY GRADED
A+| ||PROFESSOR VERIFIED||
Section 1: Foundational Assessment & Vital Signs (Q1-20)
1. Q: A nurse is preparing to assess a new client. Which action should the nurse
perform first?
A. Review the client’s medical record.
B. Introduce themselves and explain the purpose of the assessment.
C. Gather all necessary equipment.
D. Perform hand hygiene.
A: B. Introduce themselves and explain the purpose of the assessment. The first step is always
to establish the nurse-client relationship, ensure consent, and reduce anxiety.
2. Q: When percussing over a dense organ like the liver, the expected sound is:
A. Tympany.
B. Resonance.
C. Dullness.
D. Hyperresonance.
A: C. Dullness. Dullness is heard over solid organs (liver, spleen, heart) or fluid.
3. Q: A client’s blood pressure reading is 152/94 mmHg. How should the nurse
categorize this?
A. Prehypertension
B. Stage 1 Hypertension
C. Stage 2 Hypertension
D. Hypertensive Crisis
A: B. Stage 1 Hypertension. According to AHA guidelines, Stage 1 is SBP 130-139 or DBP 80-89.
,However, a single reading is not diagnostic; it requires an average of two or more readings on
separate occasions.
4. Q: The nurse palpates a radial pulse that is irregular in rhythm and weak in strength.
What is the priority action?
A. Document the finding.
B. Assess the apical pulse for a full minute.
C. Check the pulse in the other arm.
D. Ask the client if they feel dizzy.
A: B. Assess the apical pulse for a full minute. An irregular pulse requires a full minute apical
assessment for accuracy to detect a pulse deficit.
5. Q: What is the normal range for oxygen saturation (SpO2) in a healthy adult?
A. 75-85%
B. 88-92%
C. 95-100%
D. 100% only
A: C. 95-100%. Values below 95% often require investigation, though targets may be lower for
clients with chronic lung conditions like COPD.
6. Q: To accurately assess a client’s respiratory rate, the nurse should:
A. Inform the client they are counting their breaths.
B. Count for 15 seconds and multiply by 4, after pulse assessment.
C. Keep fingers on the radial pulse while observing the chest rise.
D. Ask the client to breathe deeply.
A: C. Keep fingers on the radial pulse while observing the chest rise. This prevents the client
from altering their breathing pattern (conscious control).
7. Q: A client has a temperature of 38.8°C (101.8°F). Which accompanying finding
requires immediate intervention?
A. Flushed, warm skin.
B. Heart rate of 102 bpm.
C. Altered mental status/confusion.
D. Complaints of muscle aches.
A: C. Altered mental status/confusion. This is a sign of possible severe infection or sepsis and
indicates a worsening condition.
8. Q: The difference between a client’s systolic and diastolic blood pressure is called:
A. Pulse pressure.
B. Mean arterial pressure (MAP).
,C. Auscultatory gap.
D. Orthostatic pressure.
A: A. Pulse pressure. Normal is about 40 mmHg. A narrow or wide pulse pressure can indicate
specific pathologies.
9. Q: When assessing for orthostatic hypotension, a positive finding is indicated by:
A. An increase in heart rate of 10 bpm.
B. A drop in systolic BP of 20 mmHg or more, or a drop in diastolic BP of 10 mmHg or more.
C. The client feeling lightheaded immediately upon standing.
D. All of the above.
A: B. A drop in systolic BP of 20 mmHg or more, or a drop in diastolic BP of 10 mmHg or
more. While symptoms (C) are important, the diagnosis is based on these specific BP criteria.
10. Q: A tympanic thermometer is contraindicated for which client?
A. A 4-year-old with an ear infection.
B. A 40-year-old who is asleep.
C. A 70-year-old with hypertension.
D. It is never contraindicated.
A: A. A 4-year-old with an ear infection. Otitis media or cerumen impaction can distort the
reading and cause discomfort.
(Q11-20 continue with topics like pain assessment scales, developmental considerations for
vitals, MAP calculation, etc.)
Section 2: Head-to-Toe Physical Assessment (Q21-50)
21. Q: During a head assessment, the nurse notes the client’s sclera has a yellow tinge.
This should be documented as:
A. Cyanosis.
B. Jaundice.
C. Pallor.
D. Ecchymosis.
A: B. Jaundice. Yellowing of the sclera (icterus) indicates hyperbilirubinemia.
22. Q: The nurse is testing cranial nerve VIII. Which action is correct?
A. Ask the client to stick out their tongue.
B. Perform the whisper test or use a tuning fork (Rinne/Weber).
C. Shine a light into the client’s pupil.
D. Ask the client to smile and show their teeth.
A: B. Perform the whisper test or use a tuning fork. Cranial nerve VIII is the
Acoustic/Vestibulocochlear nerve, responsible for hearing and balance.
, 23. Q: A client has diminished breath sounds in the left lower lobe posteriorly. To further
assess, the nurse should:
A. Ask the client to cough, then listen again.
B. Percuss the area for dullness.
C. Have the client lean forward and listen.
D. Both A and B.
A: D. Both A and B. Coughing may clear temporary atelectasis. Percussion for dullness would
indicate consolidation (e.g., pneumonia) or effusion, which could explain diminished sounds.
24. Q: When auscultating heart sounds, the "lub" (S1) sound is best heard at the:
A. Apex of the heart (mitral area).
B. 2nd right intercostal space (aortic area).
C. 2nd left intercostal space (pulmonic area).
D. Lower left sternal border (tricuspid area).
A: A. Apex of the heart (mitral area). S1, caused by closure of the AV valves (mitral & tricuspid),
is loudest at the apex.
25. Q: The nurse palpates a pulsating mass in the client’s abdomen. What is
the priority action?
A. Measure the abdominal girth.
B. Auscultate the area for a bruit.
C. Notify the provider immediately.
D. Ask about a history of constipation.
A: C. Notify the provider immediately. A pulsating mass, especially in the epigastric area, is a
potential sign of an abdominal aortic aneurysm (AAA), which is a medical emergency.
26. Q: Capillary refill time is assessed to evaluate:
A. Peripheral perfusion and cardiac output.
B. Neurological function.
C. Nutritional status.
D. Hydration status only.
A: A. Peripheral perfusion and cardiac output. Normal refill is <2-3 seconds. Prolonged refill
indicates poor perfusion.
27. Q: To assess for pitting edema, the nurse presses firmly against the client’s ankle for
5 seconds. A deep pit (8mm) that lasts for over 2 minutes is graded as:
A. 1+ edema.
B. 2+ edema.
C. 3+ edema.
