1|Page
BSN 246 HESI Health Assessment V1 Exam 2026/2027 |
Actual Exam Questions with Verified Answers & Detailed
Rationales | Nightingale College Grade A Study Guide
1. A nurse is performing a thoracic assessment on a client with chronic asthma and
hyperinflation of the lungs. Which finding should the nurse expect?
A. Clubbing of the fingers
B. Barrel chest
C. Pursed-lip breathing
D. Asymmetrical chest expansion
Correct Answer: B. Barrel chest
Rationale: Chronic asthma and hyperinflation lead to air trapping and overexpansion of
the lungs. This results in a barrel chest, characterized by an increased anteroposterior
diameter, which is an expected finding in clients with chronic obstructive pulmonary
diseases.
,2|Page
2. A nurse is assessing a client's bowel sounds and hears them in the right upper
quadrant. What is the nurse's next action?
A. Document the presence of bowel sounds in all four quadrants.
B. Notify the healthcare provider of the finding.
C. Note the character and frequency of the bowel sounds.
D. Auscultate for vascular sounds, such as bruits.
Correct Answer: C. Note the character and frequency of the bowel sounds.
Rationale: After confirming the presence of bowel sounds, the nurse's next step is to
assess their character (e.g., high-pitched, gurgling) and frequency (
remove margins after each question
Here is the revised document with the margins removed after each question for a
cleaner, more concise format.
1. A nurse is performing a thoracic assessment on a client with chronic asthma and
hyperinflation of the lungs. Which finding should the nurse expect?
A. Clubbing of the fingers
B. Barrel chest
C. Pursed-lip breathing
D. Asymmetrical chest expansion
,3|Page
Correct Answer: B. Barrel chest
Rationale: Chronic asthma and hyperinflation lead to air trapping and overexpansion of
the lungs. This results in a barrel chest, characterized by an increased anteroposterior
diameter, which is an expected finding in clients with chronic obstructive pulmonary
diseases.
2. A nurse is assessing a client's bowel sounds and hears them in the right upper
quadrant. What is the nurse's next action?
A. Document the presence of bowel sounds in all four quadrants.
B. Notify the healthcare provider of the finding.
C. Note the character and frequency of the bowel sounds.
D. Auscultate for vascular sounds, such as bruits.
Correct Answer: C. Note the character and frequency of the bowel sounds.
Rationale: After confirming the presence of bowel sounds, the nurse's next step is to
assess their character (e.g., high-pitched, gurgling) and frequency (e.g., 5-30 per
minute). This detailed assessment provides more comprehensive data than simply
documenting their presence.
, 4|Page
3. During inspection of a client's mouth and pharynx, the nurse places a tongue blade on
the back of the tongue, which causes the client to gag. After removing the tongue blade,
what action should the nurse take?
A. Assess the client's ability to swallow.
B. Document an intact gag reflex.
C. Notify the healthcare provider of a hypersensitive gag reflex.
D. Reassure the client that this is an abnormal response.
Correct Answer: B. Document an intact gag reflex.
Rationale: The gag reflex is a normal protective mechanism mediated by cranial nerves
IX (glossopharyngeal) and X (vagus). Eliciting a gag reflex during an oral exam indicates
that these nerves are intact, and this finding should be documented as normal.
4. When teaching a client how to perform a monthly breast self-assessment, the nurse
should tell the client that it is most important to assess which part of the breast more
closely for changes?
A. Upper outer quadrant
B. Upper inner quadrant
C. Lower outer quadrant
D. Tail of Spence
BSN 246 HESI Health Assessment V1 Exam 2026/2027 |
Actual Exam Questions with Verified Answers & Detailed
Rationales | Nightingale College Grade A Study Guide
1. A nurse is performing a thoracic assessment on a client with chronic asthma and
hyperinflation of the lungs. Which finding should the nurse expect?
A. Clubbing of the fingers
B. Barrel chest
C. Pursed-lip breathing
D. Asymmetrical chest expansion
Correct Answer: B. Barrel chest
Rationale: Chronic asthma and hyperinflation lead to air trapping and overexpansion of
the lungs. This results in a barrel chest, characterized by an increased anteroposterior
diameter, which is an expected finding in clients with chronic obstructive pulmonary
diseases.
,2|Page
2. A nurse is assessing a client's bowel sounds and hears them in the right upper
quadrant. What is the nurse's next action?
A. Document the presence of bowel sounds in all four quadrants.
B. Notify the healthcare provider of the finding.
C. Note the character and frequency of the bowel sounds.
D. Auscultate for vascular sounds, such as bruits.
Correct Answer: C. Note the character and frequency of the bowel sounds.
Rationale: After confirming the presence of bowel sounds, the nurse's next step is to
assess their character (e.g., high-pitched, gurgling) and frequency (
remove margins after each question
Here is the revised document with the margins removed after each question for a
cleaner, more concise format.
1. A nurse is performing a thoracic assessment on a client with chronic asthma and
hyperinflation of the lungs. Which finding should the nurse expect?
A. Clubbing of the fingers
B. Barrel chest
C. Pursed-lip breathing
D. Asymmetrical chest expansion
,3|Page
Correct Answer: B. Barrel chest
Rationale: Chronic asthma and hyperinflation lead to air trapping and overexpansion of
the lungs. This results in a barrel chest, characterized by an increased anteroposterior
diameter, which is an expected finding in clients with chronic obstructive pulmonary
diseases.
2. A nurse is assessing a client's bowel sounds and hears them in the right upper
quadrant. What is the nurse's next action?
A. Document the presence of bowel sounds in all four quadrants.
B. Notify the healthcare provider of the finding.
C. Note the character and frequency of the bowel sounds.
D. Auscultate for vascular sounds, such as bruits.
Correct Answer: C. Note the character and frequency of the bowel sounds.
Rationale: After confirming the presence of bowel sounds, the nurse's next step is to
assess their character (e.g., high-pitched, gurgling) and frequency (e.g., 5-30 per
minute). This detailed assessment provides more comprehensive data than simply
documenting their presence.
, 4|Page
3. During inspection of a client's mouth and pharynx, the nurse places a tongue blade on
the back of the tongue, which causes the client to gag. After removing the tongue blade,
what action should the nurse take?
A. Assess the client's ability to swallow.
B. Document an intact gag reflex.
C. Notify the healthcare provider of a hypersensitive gag reflex.
D. Reassure the client that this is an abnormal response.
Correct Answer: B. Document an intact gag reflex.
Rationale: The gag reflex is a normal protective mechanism mediated by cranial nerves
IX (glossopharyngeal) and X (vagus). Eliciting a gag reflex during an oral exam indicates
that these nerves are intact, and this finding should be documented as normal.
4. When teaching a client how to perform a monthly breast self-assessment, the nurse
should tell the client that it is most important to assess which part of the breast more
closely for changes?
A. Upper outer quadrant
B. Upper inner quadrant
C. Lower outer quadrant
D. Tail of Spence
