lOMoARcPSD|27916040
BSN 246 HESI HEALTH
ASSESSMENT
130 QUESTIONS AND CORRECT ANSWERS UPDATED
1. The primary nurse asks another nurse to assist in checking a client for an apical-radial
pulse deficit. One nurse counts an apical pulse of 72 beats/minute while the other nurse
counts a radial pulse of 88 beats/minute. Which action should the primary nurse take?
A Check the reading after the other nurse leaves the room.
B Document a pulse deficit of 16 beats per minute.
C Report the results of the deficit to the healthcare provider. D Repeat the assessment to
obtain another reading.
Choice D
Reason:
Repeating the assessment to obtain another reading is appropriate. This option prioritizes patient safety by acknowledging the
need to confirm the accuracy of the measurements. Repeating the assessment allows the nurses to ensure consistency and
reliability in their findings before taking further action or reporting to the healthcare provider.
2. The nurse observes that a client is experiencing melena. Which serum laboratory test
should the nurse monitor in response to this finding?
A White blood cell count (WBC).
B Glucose.
C Blood urea nitrogen (BUN). D Hematocrit.
Hematocrit is the correct answer. Hematocrit levels are crucial to monitor in cases of melena because they provide information
about the client’s red blood cell volume and can indicate the extent of blood loss.
AI: Yes, a hematocrit test can indirectly measure the presence of melena (black, tarry stools indicating gastrointestinal bleeding)
by showing a low red blood cell count, which is a key indicator of blood loss and therefore can suggest bleeding in the
gastrointestinal tract, including melena
3. When obtaining a client's health history related to smoking cigarettes, the nurse plans
to determine the client's smoking pack years. Which information should the nurse
obtain for this calculation? Select all that apply.
A Number of attempts to quit smoking.
B Packs of cigarettes smoked per day. C Client's current age.
D Number of years the client smoked.
E Age when the client started smoking.
Answer: C. Age when the client started smoking.
Knowing when the client began smoking is essential for determining the total duration of smoking. This information allows the nurse to calculate how
long the client has been exposed to tobacco, which is critical for assessing potential health risks associated with their smoking history.
D. Packs of cigarettes smoked per day.
, lOMoARcPSD|27916040
This information is crucial as it directly contributes to the calculation of pack years. Understanding how many packs the client smokes each day helps
quantify their level of tobacco exposure. For instance, smoking one pack per day for ten years results in ten pack years, while two packs per day over the
same period would lead to twenty pack years.
E. Number of years the client smoked.
This detail is necessary to determine the total duration of the smoking habit. The total number of years smoked, combined with the daily pack
consumption, provides a comprehensive view of the client's smoking history. It allows the nurse to assess the cumulative risk associated with long-term
tobacco use, which is important for evaluating the client’s health and potential interventions.
4. The nurse is performing an admission assessment for a client with pyelonephritis who
has urgency and burning while urinating. Which finding indicates an expected response
when the nurse percusses the costovertebral angle?
A Audible thud without pain.
B Rigidity and firmness.
C Rebound tenderness. D Sharp, severe pain.
Pyelonephritis: kidney infection
Choice D Reason:
Sharp, severe pain is correct. Sharp, severe pain upon percussing the CVA suggests tenderness, which can be indicative of
kidney inflammation or infection, such as pyelonephritis. This finding would support the diagnosis and help guide further
assessment and treatment.
5. In assessing a client's level of consciousness, what should the nurse assess first?
A Motor response.
B Eye opening.
C Control Pane
D Level of alertness.
6. In reading a client's record, the nurse notes that the client is experiencing tinnitus.
Which assessment provides the nurse with the information needed to evaluate the
effects of this condition?
A Observe chest and upper neck for a rash.
B Perform a hearing test.
C Evaluate for a loss of peripheral vision. D Assess deep tendon reflexes.
Tinnitus: the perception of sound when there's no external source, such as ringing in the ears, but it can also sound like buzzing,
roaring, or hissing
7. While assessing a client, the nurse notices that the client's legs are asymmetrical. Which
additional physical data should the nurse collect?
A Perform passive range of motion and compare the findings.
B Compare measured circumferences of each extremity joint.
C Instruct client to walk across room and observe the gait.
D Measure the length of each leg and document the findings.
** has two answers of compare or measure..
, lOMoARcPSD|27916040
8. The nurse is performing an initial assessment of a client who has an expressionless
facial affect, slurred speech, and red conjunctivae. Which question should the nurse ask
first? “Have you…”
A “ever had problems with your blood sugar?"
B “been sleeping well?
C “had anything to eat in the last 24 hours?
D “been depressed lately?
9. The nurse observes an older adult client walking aimlessly in the hallway and staring
straight ahead with a blank expression. How should the nurse enter documentation of
this finding in the client's electronic medical record (EMR)?
A Appears confused and depressed.
B Demonstrates signs of early dementia.
C Ambulatory and disoriented to place. D Wandering behavior with flat affect.
This statement is accurate, objective, and based on observable behaviors. "Wandering behavior" describes the client's aimless
walking, and "flat affect" refers to the blank expression. This documentation does not make assumptions about the client's
mental state beyond what is directly observable.
10. The nurse is examining the abdomen of an older male client who expresses suprapubic
tenderness on palpation. The client states that it sometimes feels like there is still
pressure in that area after urination. Which additional finding should the nurse expect
with continued interview of the client?
A Black tarry stool.
B A cloudy discharge.
C An overactive bladder D A weak urinary stream.
11. A client is seen in the emergent care clinic for right wrist pain with a pattern of
ecchymosis observed on the wrist. Which motion should the nurse instruct the client to
perform to assess the wrist mobility?
A Hyperextension and palmar flexion.
B Plantar flexion.
C Forearm pronation.
D Forearm supination.
12. While making a home visit, the spouse of an older client tells the nurse the client is
becoming increasingly confused about past events and has started forgetting to all pain
dictation for osteoarthritis in the knees. Which assessment should the nurse initially
perform to evaluate the client's memory?
BSN 246 HESI HEALTH
ASSESSMENT
130 QUESTIONS AND CORRECT ANSWERS UPDATED
1. The primary nurse asks another nurse to assist in checking a client for an apical-radial
pulse deficit. One nurse counts an apical pulse of 72 beats/minute while the other nurse
counts a radial pulse of 88 beats/minute. Which action should the primary nurse take?
A Check the reading after the other nurse leaves the room.
B Document a pulse deficit of 16 beats per minute.
C Report the results of the deficit to the healthcare provider. D Repeat the assessment to
obtain another reading.
Choice D
Reason:
Repeating the assessment to obtain another reading is appropriate. This option prioritizes patient safety by acknowledging the
need to confirm the accuracy of the measurements. Repeating the assessment allows the nurses to ensure consistency and
reliability in their findings before taking further action or reporting to the healthcare provider.
2. The nurse observes that a client is experiencing melena. Which serum laboratory test
should the nurse monitor in response to this finding?
A White blood cell count (WBC).
B Glucose.
C Blood urea nitrogen (BUN). D Hematocrit.
Hematocrit is the correct answer. Hematocrit levels are crucial to monitor in cases of melena because they provide information
about the client’s red blood cell volume and can indicate the extent of blood loss.
AI: Yes, a hematocrit test can indirectly measure the presence of melena (black, tarry stools indicating gastrointestinal bleeding)
by showing a low red blood cell count, which is a key indicator of blood loss and therefore can suggest bleeding in the
gastrointestinal tract, including melena
3. When obtaining a client's health history related to smoking cigarettes, the nurse plans
to determine the client's smoking pack years. Which information should the nurse
obtain for this calculation? Select all that apply.
A Number of attempts to quit smoking.
B Packs of cigarettes smoked per day. C Client's current age.
D Number of years the client smoked.
E Age when the client started smoking.
Answer: C. Age when the client started smoking.
Knowing when the client began smoking is essential for determining the total duration of smoking. This information allows the nurse to calculate how
long the client has been exposed to tobacco, which is critical for assessing potential health risks associated with their smoking history.
D. Packs of cigarettes smoked per day.
, lOMoARcPSD|27916040
This information is crucial as it directly contributes to the calculation of pack years. Understanding how many packs the client smokes each day helps
quantify their level of tobacco exposure. For instance, smoking one pack per day for ten years results in ten pack years, while two packs per day over the
same period would lead to twenty pack years.
E. Number of years the client smoked.
This detail is necessary to determine the total duration of the smoking habit. The total number of years smoked, combined with the daily pack
consumption, provides a comprehensive view of the client's smoking history. It allows the nurse to assess the cumulative risk associated with long-term
tobacco use, which is important for evaluating the client’s health and potential interventions.
4. The nurse is performing an admission assessment for a client with pyelonephritis who
has urgency and burning while urinating. Which finding indicates an expected response
when the nurse percusses the costovertebral angle?
A Audible thud without pain.
B Rigidity and firmness.
C Rebound tenderness. D Sharp, severe pain.
Pyelonephritis: kidney infection
Choice D Reason:
Sharp, severe pain is correct. Sharp, severe pain upon percussing the CVA suggests tenderness, which can be indicative of
kidney inflammation or infection, such as pyelonephritis. This finding would support the diagnosis and help guide further
assessment and treatment.
5. In assessing a client's level of consciousness, what should the nurse assess first?
A Motor response.
B Eye opening.
C Control Pane
D Level of alertness.
6. In reading a client's record, the nurse notes that the client is experiencing tinnitus.
Which assessment provides the nurse with the information needed to evaluate the
effects of this condition?
A Observe chest and upper neck for a rash.
B Perform a hearing test.
C Evaluate for a loss of peripheral vision. D Assess deep tendon reflexes.
Tinnitus: the perception of sound when there's no external source, such as ringing in the ears, but it can also sound like buzzing,
roaring, or hissing
7. While assessing a client, the nurse notices that the client's legs are asymmetrical. Which
additional physical data should the nurse collect?
A Perform passive range of motion and compare the findings.
B Compare measured circumferences of each extremity joint.
C Instruct client to walk across room and observe the gait.
D Measure the length of each leg and document the findings.
** has two answers of compare or measure..
, lOMoARcPSD|27916040
8. The nurse is performing an initial assessment of a client who has an expressionless
facial affect, slurred speech, and red conjunctivae. Which question should the nurse ask
first? “Have you…”
A “ever had problems with your blood sugar?"
B “been sleeping well?
C “had anything to eat in the last 24 hours?
D “been depressed lately?
9. The nurse observes an older adult client walking aimlessly in the hallway and staring
straight ahead with a blank expression. How should the nurse enter documentation of
this finding in the client's electronic medical record (EMR)?
A Appears confused and depressed.
B Demonstrates signs of early dementia.
C Ambulatory and disoriented to place. D Wandering behavior with flat affect.
This statement is accurate, objective, and based on observable behaviors. "Wandering behavior" describes the client's aimless
walking, and "flat affect" refers to the blank expression. This documentation does not make assumptions about the client's
mental state beyond what is directly observable.
10. The nurse is examining the abdomen of an older male client who expresses suprapubic
tenderness on palpation. The client states that it sometimes feels like there is still
pressure in that area after urination. Which additional finding should the nurse expect
with continued interview of the client?
A Black tarry stool.
B A cloudy discharge.
C An overactive bladder D A weak urinary stream.
11. A client is seen in the emergent care clinic for right wrist pain with a pattern of
ecchymosis observed on the wrist. Which motion should the nurse instruct the client to
perform to assess the wrist mobility?
A Hyperextension and palmar flexion.
B Plantar flexion.
C Forearm pronation.
D Forearm supination.
12. While making a home visit, the spouse of an older client tells the nurse the client is
becoming increasingly confused about past events and has started forgetting to all pain
dictation for osteoarthritis in the knees. Which assessment should the nurse initially
perform to evaluate the client's memory?
