HESI Health
Assessment Exam
Questions and
Answers
The nurse is caring for a patient with chronic A
lower back pain. The nurse knows that the
most reliable indicator of pain in this client is:
The patient is reporting "6/10" pain.
The patient is refusing to get out of bed.
The patient is refusing to eat breakfast.
The patient's heart rate is 90 beats per minute.
Which of the following actions should the B
nurse take to ensure an accurate blood The patient's arm should be supported at heart level. Separate BP
pressure (BP) reading? readings may need to be taken, but not one right after the
other.
The length of the BP bladder should equal 80% of the arm
Ensure the width of the BP cuff is equal to 80% circumferen
of the arm circumference.
Ensure the client's back is supported and feet
are flat on the ground.
Take two BP readings 20 seconds apart.
Ensure that the patient's arm is above heart
level.
,The nurse obtains which piece of data during A
the general survey?
Client is alert and calm.
Client's heart rate is 80 beats per minute.
Client's body mass index (BMI) is 30.
Client's lung sounds are "clear" to auscultation.
A man is at the clinic for a complete physical A
exam. He states that he is "very anxious". What
steps can the nurse take to make him more
comfortable?
Appear confident and unhurried during the
exam.
Measure vital signs at the end to allow the
patient sufficient time to relax.
Let him leave his clothes on during the
examination.
Obtain another nurse to examine the patient.
A father brings his 13 month-old child in for C
"fever" and he reports that the child has been
"pulling on his left ear". Upon entering the
exam room, the child is asleep in the father's
arms. The nurse should perform which
assessment first?
Use the otoscope to look inside the ear.
Use a penlight to check the eyes and
nose. Auscultate the lungs, heart, and
abdomen.
Assess gross motor skills using the Denver II
screening tool.
,An 18 year-old presents to the emergency A- constricted pupils are a sign of recent opioid use, the rest
are department with "headache." Which of these withdrawals
assessment findings alerts the nurse to recent
opioid use?
Pupillary constriction
Hallucinations.
Fever.
Tachypnea.
While collecting the pulse on a 26 year-old C
client, the nurse notes that the heart rate
seems to speed up and then slow down
in accordance with respirations. The pulse
is counted at 80 beats per minute. What
should the nurse do next?
Obtain orthostatic vital signs.
Notify the physician.
Document "sinus arrhythmia."
Use a doppler to confirm the finding.
An elderly client with pneumonia is being D
treated in the intensive care unit (ICU). He is
acutely agitated, restless, and disoriented. The
nurse documents his level of consciousness as:
Manic.
Demented.
Drowsy.
Delirious.
, The nurse is assessing a newborn infant. How C
should the nurse measure the heart rate (HR)?
Palpate the radial pulse for 15 seconds and
multiply by four.
Palpate the brachial pulse for 30 seconds and
multiply by two.
Auscultate the apical site for 60 seconds.
Apply a pulse oximeter to obtain both the
HR and SpO2.
A 28 year-old is brought to the emergency A- hallucinations and delirium are commonly seen w
alcohol department. He is disoriented and withdrawal
hallucinating, and vital signs are elevated. The
nurse suspects that the patient is experiencing
withdrawal symptoms from which substance?
Alcohol.
Cocaine.
Cannabis.
Opiates.
Assessment Exam
Questions and
Answers
The nurse is caring for a patient with chronic A
lower back pain. The nurse knows that the
most reliable indicator of pain in this client is:
The patient is reporting "6/10" pain.
The patient is refusing to get out of bed.
The patient is refusing to eat breakfast.
The patient's heart rate is 90 beats per minute.
Which of the following actions should the B
nurse take to ensure an accurate blood The patient's arm should be supported at heart level. Separate BP
pressure (BP) reading? readings may need to be taken, but not one right after the
other.
The length of the BP bladder should equal 80% of the arm
Ensure the width of the BP cuff is equal to 80% circumferen
of the arm circumference.
Ensure the client's back is supported and feet
are flat on the ground.
Take two BP readings 20 seconds apart.
Ensure that the patient's arm is above heart
level.
,The nurse obtains which piece of data during A
the general survey?
Client is alert and calm.
Client's heart rate is 80 beats per minute.
Client's body mass index (BMI) is 30.
Client's lung sounds are "clear" to auscultation.
A man is at the clinic for a complete physical A
exam. He states that he is "very anxious". What
steps can the nurse take to make him more
comfortable?
Appear confident and unhurried during the
exam.
Measure vital signs at the end to allow the
patient sufficient time to relax.
Let him leave his clothes on during the
examination.
Obtain another nurse to examine the patient.
A father brings his 13 month-old child in for C
"fever" and he reports that the child has been
"pulling on his left ear". Upon entering the
exam room, the child is asleep in the father's
arms. The nurse should perform which
assessment first?
Use the otoscope to look inside the ear.
Use a penlight to check the eyes and
nose. Auscultate the lungs, heart, and
abdomen.
Assess gross motor skills using the Denver II
screening tool.
,An 18 year-old presents to the emergency A- constricted pupils are a sign of recent opioid use, the rest
are department with "headache." Which of these withdrawals
assessment findings alerts the nurse to recent
opioid use?
Pupillary constriction
Hallucinations.
Fever.
Tachypnea.
While collecting the pulse on a 26 year-old C
client, the nurse notes that the heart rate
seems to speed up and then slow down
in accordance with respirations. The pulse
is counted at 80 beats per minute. What
should the nurse do next?
Obtain orthostatic vital signs.
Notify the physician.
Document "sinus arrhythmia."
Use a doppler to confirm the finding.
An elderly client with pneumonia is being D
treated in the intensive care unit (ICU). He is
acutely agitated, restless, and disoriented. The
nurse documents his level of consciousness as:
Manic.
Demented.
Drowsy.
Delirious.
, The nurse is assessing a newborn infant. How C
should the nurse measure the heart rate (HR)?
Palpate the radial pulse for 15 seconds and
multiply by four.
Palpate the brachial pulse for 30 seconds and
multiply by two.
Auscultate the apical site for 60 seconds.
Apply a pulse oximeter to obtain both the
HR and SpO2.
A 28 year-old is brought to the emergency A- hallucinations and delirium are commonly seen w
alcohol department. He is disoriented and withdrawal
hallucinating, and vital signs are elevated. The
nurse suspects that the patient is experiencing
withdrawal symptoms from which substance?
Alcohol.
Cocaine.
Cannabis.
Opiates.
