BSN 246 HESI Health Assessment Exam V1
ACTUAL EXAM 2026/2027 | Elsevier HESI
Nursing Program | Verified Q&A | Pass
Guaranteed - A+ Graded
Section 1 – General Survey & Vital Signs (10 Questions)
Q1: A 68-year-old male is admitted for elective surgery. His morning vital signs are: BP 138/88 mmHg,
HR 72 bpm, RR 14/min, temp 37.2°C (99.0°F) oral, SpO₂ 96% on room air. Which finding requires follow-
up?
Blood pressure indicating Stage 1 hypertension requiring immediate intervention
Heart rate of 72 bpm indicating bradycardia
Respiratory rate of 14/min indicating hypoventilation
Temperature of 37.2°C indicating low-grade fever requiring investigation. [CORRECT]
Correct Answer: D
Rationale: While 37.2°C is slightly above normal oral temperature range (36.0–37.0°C), it may indicate
early infection in a pre-surgical patient requiring investigation. The incorrect interpretation of BP 138/88
as requiring immediate intervention is wrong because this is elevated but not hypertensive crisis; 72
bpm is normal (60–100), and 14/min RR is within normal range (12–20).
Q2: A nurse measures a patient's blood pressure using a cuff with a bladder width that covers only 30%
of the arm circumference. What is the expected effect on the reading?
Falsely elevated blood pressure due to incomplete compression. [CORRECT]
Falsely decreased blood pressure due to inadequate compression
No effect on the reading if the cuff is wrapped tightly
Accurate reading if the patient's arm is positioned above heart level
,Correct Answer: A
Rationale: A cuff that is too narrow relative to arm circumference (should be 40%) requires excessive
pressure to occlude the brachial artery, yielding falsely high readings. The incorrect suggestion of falsely
decreased pressure applies to cuffs that are too wide; positioning above heart level would further
decrease pressure, not compensate for cuff size.
Q3: When assessing a patient for orthostatic hypotension, which technique is correct?
Measure BP supine, then immediately upon standing, then at 5 minutes
Measure BP after the patient has been standing for 10 minutes continuously
Measure BP supine after 2 minutes, then sitting, then standing within 3 minutes, comparing
readings. [CORRECT]
Measure BP only while supine since standing measurements are unreliable
Correct Answer: C
Rationale: Orthostatic hypotension is defined as a drop >20 mmHg systolic or >10 mmHg diastolic within
3 minutes of standing, with symptoms. The incorrect technique of immediate measurement upon
standing misses the 3-minute window; waiting 5 or 10 minutes misses acute changes, and omitting
standing measurements prevents diagnosis.
Q4: A nurse assesses a patient's pain using the PQRSTU mnemonic. The patient reports sharp chest pain
rated 8/10 that started 30 minutes ago while walking, radiates to the left arm, and is unrelieved by rest.
What does the "U" in PQRSTU assess?
Urinary symptoms associated with the pain
Understanding the patient's perception and impact of the pain on daily life. [CORRECT]
Urgency of the medical condition requiring immediate intervention
Underlying pathophysiology of the pain mechanism
Correct Answer: B
Rationale: The "U" stands for Understanding/How the pain affects the patient—exploring meaning,
impact on function, and coping. The incorrect options misinterpret the mnemonic: urinary symptoms
are not part of standard pain assessment, urgency is inferred from severity not "U," and underlying
pathophysiology is determined by providers not this mnemonic.
, Q5: A 5-year-old child is crying after a minor injury. Which pain assessment tool is most appropriate?
Numeric Rating Scale 0–10
Visual Analog Scale
Wong-Baker FACES Pain Rating Scale. [CORRECT]
McGill Pain Questionnaire
Correct Answer: C
Rationale: The Wong-Baker FACES scale uses simple faces corresponding to pain levels 0–10,
appropriate for children 3 years and older who may not understand numeric scales. The incorrect
options require abstract number concepts (Numeric, VAS) or extensive vocabulary (McGill) beyond
typical 5-year-old capability.
Q6: A patient's peripheral pulse is documented as "2+". What does this grading indicate?
Absent pulse
Weak, barely palpable pulse
Normal, easily palpable pulse. [CORRECT]
Bounding, full pulse
Correct Answer: C
Rationale: The 0–4+ pulse grading scale defines 2+ as normal, easily palpable pulse. The incorrect
interpretations describe 0 (absent), 1+ (weak/thready), and 3+ (bounding) respectively; 4+ would be
aneurysmal.
Q7: A nurse obtains a tympanic temperature of 38.5°C (101.3°F) on a patient with cerumen impaction.
What is the most appropriate action?
Document as fever and notify provider immediately
Recheck using oral or temporal method as cerumen may falsely lower reading. [CORRECT]
Recheck using rectal method as this is most accurate
Accept reading as accurate since tympanic is reliable in all patients
Correct Answer: B
Rationale: Cerumen (earwax) insulates the tympanic membrane and can falsely lower temperature
ACTUAL EXAM 2026/2027 | Elsevier HESI
Nursing Program | Verified Q&A | Pass
Guaranteed - A+ Graded
Section 1 – General Survey & Vital Signs (10 Questions)
Q1: A 68-year-old male is admitted for elective surgery. His morning vital signs are: BP 138/88 mmHg,
HR 72 bpm, RR 14/min, temp 37.2°C (99.0°F) oral, SpO₂ 96% on room air. Which finding requires follow-
up?
Blood pressure indicating Stage 1 hypertension requiring immediate intervention
Heart rate of 72 bpm indicating bradycardia
Respiratory rate of 14/min indicating hypoventilation
Temperature of 37.2°C indicating low-grade fever requiring investigation. [CORRECT]
Correct Answer: D
Rationale: While 37.2°C is slightly above normal oral temperature range (36.0–37.0°C), it may indicate
early infection in a pre-surgical patient requiring investigation. The incorrect interpretation of BP 138/88
as requiring immediate intervention is wrong because this is elevated but not hypertensive crisis; 72
bpm is normal (60–100), and 14/min RR is within normal range (12–20).
Q2: A nurse measures a patient's blood pressure using a cuff with a bladder width that covers only 30%
of the arm circumference. What is the expected effect on the reading?
Falsely elevated blood pressure due to incomplete compression. [CORRECT]
Falsely decreased blood pressure due to inadequate compression
No effect on the reading if the cuff is wrapped tightly
Accurate reading if the patient's arm is positioned above heart level
,Correct Answer: A
Rationale: A cuff that is too narrow relative to arm circumference (should be 40%) requires excessive
pressure to occlude the brachial artery, yielding falsely high readings. The incorrect suggestion of falsely
decreased pressure applies to cuffs that are too wide; positioning above heart level would further
decrease pressure, not compensate for cuff size.
Q3: When assessing a patient for orthostatic hypotension, which technique is correct?
Measure BP supine, then immediately upon standing, then at 5 minutes
Measure BP after the patient has been standing for 10 minutes continuously
Measure BP supine after 2 minutes, then sitting, then standing within 3 minutes, comparing
readings. [CORRECT]
Measure BP only while supine since standing measurements are unreliable
Correct Answer: C
Rationale: Orthostatic hypotension is defined as a drop >20 mmHg systolic or >10 mmHg diastolic within
3 minutes of standing, with symptoms. The incorrect technique of immediate measurement upon
standing misses the 3-minute window; waiting 5 or 10 minutes misses acute changes, and omitting
standing measurements prevents diagnosis.
Q4: A nurse assesses a patient's pain using the PQRSTU mnemonic. The patient reports sharp chest pain
rated 8/10 that started 30 minutes ago while walking, radiates to the left arm, and is unrelieved by rest.
What does the "U" in PQRSTU assess?
Urinary symptoms associated with the pain
Understanding the patient's perception and impact of the pain on daily life. [CORRECT]
Urgency of the medical condition requiring immediate intervention
Underlying pathophysiology of the pain mechanism
Correct Answer: B
Rationale: The "U" stands for Understanding/How the pain affects the patient—exploring meaning,
impact on function, and coping. The incorrect options misinterpret the mnemonic: urinary symptoms
are not part of standard pain assessment, urgency is inferred from severity not "U," and underlying
pathophysiology is determined by providers not this mnemonic.
, Q5: A 5-year-old child is crying after a minor injury. Which pain assessment tool is most appropriate?
Numeric Rating Scale 0–10
Visual Analog Scale
Wong-Baker FACES Pain Rating Scale. [CORRECT]
McGill Pain Questionnaire
Correct Answer: C
Rationale: The Wong-Baker FACES scale uses simple faces corresponding to pain levels 0–10,
appropriate for children 3 years and older who may not understand numeric scales. The incorrect
options require abstract number concepts (Numeric, VAS) or extensive vocabulary (McGill) beyond
typical 5-year-old capability.
Q6: A patient's peripheral pulse is documented as "2+". What does this grading indicate?
Absent pulse
Weak, barely palpable pulse
Normal, easily palpable pulse. [CORRECT]
Bounding, full pulse
Correct Answer: C
Rationale: The 0–4+ pulse grading scale defines 2+ as normal, easily palpable pulse. The incorrect
interpretations describe 0 (absent), 1+ (weak/thready), and 3+ (bounding) respectively; 4+ would be
aneurysmal.
Q7: A nurse obtains a tympanic temperature of 38.5°C (101.3°F) on a patient with cerumen impaction.
What is the most appropriate action?
Document as fever and notify provider immediately
Recheck using oral or temporal method as cerumen may falsely lower reading. [CORRECT]
Recheck using rectal method as this is most accurate
Accept reading as accurate since tympanic is reliable in all patients
Correct Answer: B
Rationale: Cerumen (earwax) insulates the tympanic membrane and can falsely lower temperature
