HESI Module 2 Health Promotion and Disease Prevention
1. A nurse is preparing to auscultate a client's breath sounds. To assess
vesic-ular breath sounds, the nurse places the stethoscope over?
Answer: - The peripheral lungfields
Rationale: Vesicular breath sounds are heard over the peripheral lung fields,
whereair flows through the smaller bronchioles and alveoli.
Bronchovesicular breath sounds are heard over the major bronchi. Bronchial
(tracheal) breath sounds are heard over the trachea and larynx. Breath
sounds are not heard over the xiphoid process.
2. A nurse palpates a client's radial pulse, noting the rate, rhythm, and
force,and concludes that the client's pulse is normal. Which of the
following nota- tions would the nurse make in the client's record to
document the force of theclient's pulse?
Answer: 2+
Rationale: When assessing a pulse, the nurse should note the rhythm,
amplitude, and symmetry of pulses and should compare peripheral pulses on
the two sides forrate, rhythm, and quality. A 4-point scale may be used to assess
,the force (amplitude)of the pulse: 4+, bounding pulse; 3+, increased pulse;
2+, normal pulse; 1+, weak pulse. In this case the nurse would grade the
client's pulse as 2+.
3. Performing an abdominal assessment, a nurse auscultates before
palpatingand percussing the abdomen. The nurse performs the
assessment in this manner because?
Answer: Palpation and percussion can increase peristalsis
Rationale: When performing an abdominal assessment, the nurse auscultates
theabdomen after inspection. Auscultation is done before palpation and
percussion because these assessment techniques can increase peristalsis,
which would yielda false interpretation of bowel sounds. The other options
identify incorrect reasonsfor auscultating the abdomen before palpating and
percussing it.
4. A nurse is preparing to check the breath sounds of a client. Over which
anatomic area does the nurse place the stethoscope when auscultating
for bronchial breath sounds?
Answer: Rationale: Bronchial (tracheal) breath sounds are lo- cated over the
trachea and larynx. Bronchovesicular breath sounds are located over major
bronchi. Vesicular breath sounds are located over the peripheral lung fields.
,The upper sternal area is where main bronchi are located. Breath sounds are
normally not heard over the cricoid cartilage.
5. A client who was given a diagnosis of hypertension 3 months ago is at
the clinic for a checkup. Which type of database does the nurse use in
performingan assessment?
Answer: Follow-up
, Rationale: A follow-up database is compiled to evaluate the status of an
identifiedproblem at regular and appropriate intervals. An emergency
database calls for rapid collection of the data, often at the same time
lifesaving measures are beingperformed. A complete database includes a
complete health history and a full physical examination. It describes the
client's current and past state of health andforms a baseline against which
all future changes can be measured. An episodicdatabase (problem-centered)
is compiled for a limited or short-term problem. It isfocused mainly on one
problem or body system.
6. A nurse preparing to examine a client's eyes plans to perform a
confronta-tion test. The nurse tells the client that this test measures?
Answer: Peripheral vision
Rationale: The confrontation test is a gross measure of peripheral vision. It
comparesthe client's peripheral vision with the nurse's, assuming that the
nurse's vision is normal. The nurse positions himself or herself at eye level
with the client, about 2 feet away, then directs the client to cover one eye
with an opaque card and look straight at the nurse with the other eye. The
nurse covers the eye opposite the client's covered one. The nurse then holds a
pencil or flicking finger as the target, midline between the nurse and the
client, and slowly advances it from the peripheryin several directions. The
nurse asks the client to say "now" as the target is first seen. This should
1. A nurse is preparing to auscultate a client's breath sounds. To assess
vesic-ular breath sounds, the nurse places the stethoscope over?
Answer: - The peripheral lungfields
Rationale: Vesicular breath sounds are heard over the peripheral lung fields,
whereair flows through the smaller bronchioles and alveoli.
Bronchovesicular breath sounds are heard over the major bronchi. Bronchial
(tracheal) breath sounds are heard over the trachea and larynx. Breath
sounds are not heard over the xiphoid process.
2. A nurse palpates a client's radial pulse, noting the rate, rhythm, and
force,and concludes that the client's pulse is normal. Which of the
following nota- tions would the nurse make in the client's record to
document the force of theclient's pulse?
Answer: 2+
Rationale: When assessing a pulse, the nurse should note the rhythm,
amplitude, and symmetry of pulses and should compare peripheral pulses on
the two sides forrate, rhythm, and quality. A 4-point scale may be used to assess
,the force (amplitude)of the pulse: 4+, bounding pulse; 3+, increased pulse;
2+, normal pulse; 1+, weak pulse. In this case the nurse would grade the
client's pulse as 2+.
3. Performing an abdominal assessment, a nurse auscultates before
palpatingand percussing the abdomen. The nurse performs the
assessment in this manner because?
Answer: Palpation and percussion can increase peristalsis
Rationale: When performing an abdominal assessment, the nurse auscultates
theabdomen after inspection. Auscultation is done before palpation and
percussion because these assessment techniques can increase peristalsis,
which would yielda false interpretation of bowel sounds. The other options
identify incorrect reasonsfor auscultating the abdomen before palpating and
percussing it.
4. A nurse is preparing to check the breath sounds of a client. Over which
anatomic area does the nurse place the stethoscope when auscultating
for bronchial breath sounds?
Answer: Rationale: Bronchial (tracheal) breath sounds are lo- cated over the
trachea and larynx. Bronchovesicular breath sounds are located over major
bronchi. Vesicular breath sounds are located over the peripheral lung fields.
,The upper sternal area is where main bronchi are located. Breath sounds are
normally not heard over the cricoid cartilage.
5. A client who was given a diagnosis of hypertension 3 months ago is at
the clinic for a checkup. Which type of database does the nurse use in
performingan assessment?
Answer: Follow-up
, Rationale: A follow-up database is compiled to evaluate the status of an
identifiedproblem at regular and appropriate intervals. An emergency
database calls for rapid collection of the data, often at the same time
lifesaving measures are beingperformed. A complete database includes a
complete health history and a full physical examination. It describes the
client's current and past state of health andforms a baseline against which
all future changes can be measured. An episodicdatabase (problem-centered)
is compiled for a limited or short-term problem. It isfocused mainly on one
problem or body system.
6. A nurse preparing to examine a client's eyes plans to perform a
confronta-tion test. The nurse tells the client that this test measures?
Answer: Peripheral vision
Rationale: The confrontation test is a gross measure of peripheral vision. It
comparesthe client's peripheral vision with the nurse's, assuming that the
nurse's vision is normal. The nurse positions himself or herself at eye level
with the client, about 2 feet away, then directs the client to cover one eye
with an opaque card and look straight at the nurse with the other eye. The
nurse covers the eye opposite the client's covered one. The nurse then holds a
pencil or flicking finger as the target, midline between the nurse and the
client, and slowly advances it from the peripheryin several directions. The
nurse asks the client to say "now" as the target is first seen. This should
