BSN 246 HESI Health Assessment Exam V2 (Latest 2025/ 2026 Update)
Questions & Answers| Grade A| 100% Correct (Verified Solutions)-
Nightingale
Question 1
The nurse is performing an abdominal assessment on a client. In which sequence should the
nurse perform the assessment techniques?
A) Palpation, percussion, auscultation, inspection
B) Inspection, palpation, percussion, auscultation
C) Auscultation, inspection, palpation, percussion
D) Inspection, auscultation, percussion, palpation
E) Percussion, auscultation, inspection, palpation
Correct Answer: D) Inspection, auscultation, percussion, palpation
Rationale: For an abdominal assessment, the sequence is altered to prevent the stimulation
of bowel sounds that can occur with palpation and percussion. The nurse should first
inspect the abdomen visually, then auscultate for bowel and vascular sounds, and finally
perform percussion and palpation.
Question 2
When assessing a client's pupils for their reaction to light, the nurse notes that both pupils
constrict when a light is shined into the right eye. The nurse should document this finding as a
normal:
A) Pupillary accommodation.
B) Direct and consensual response.
C) Nystagmus.
D) Strabismus.
E) Corneal light reflex.
Correct Answer: B) Direct and consensual response.
Rationale: A normal pupillary light reflex involves both a direct response (the pupil of the
eye with the light constricts) and a consensual response (the pupil of the opposite eye also
constricts simultaneously). This indicates the integrity of the optic nerve (CN II) and the
oculomotor nerve (CN III).
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Question 3
The nurse is assessing a client's level of consciousness. The client opens their eyes when their
name is called, is confused in conversation, and is able to obey a command to raise their arm.
Using the Glasgow Coma Scale (GCS), what score should the nurse assign?
A) 10
B) 11
C) 12
D) 13
E) 14
Correct Answer: D) 13
Rationale: The GCS score is calculated as follows: Eye Opening to speech = 3 points. Verbal
Response is confused = 4 points. Motor Response obeys commands = 6 points. Total Score =
3 + 4 + 6 = 13.
Question 4
While auscultating a client's heart, the nurse hears a low-pitched, scratchy, grating sound at the
apex. The sound is louder when the client is leaning forward. The nurse should suspect which of
the following conditions?
A) Mitral valve stenosis
B) Aortic regurgitation
C) Pericarditis
D) Atrial fibrillation
E) A normal finding
Correct Answer: C) Pericarditis
Rationale: This describes a pericardial friction rub, the hallmark sign of pericarditis
(inflammation of the pericardial sac). It is caused by the inflamed layers of the pericardium
rubbing against each other. Having the client sit up and lean forward brings the heart
closer to the chest wall, often making the rub more audible.
Question 5
A nurse is assessing the skin turgor of a 78-year-old client. Where is the best location to perform
this assessment?
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A) The back of the hand
B) The lower arm
C) Below the clavicle
D) The forehead
E) The palm of the hand
Correct Answer: C) Below the clavicle
Rationale: In older adults, the skin on the hands and arms often loses elasticity due to aging,
making it an unreliable site for assessing skin turgor. The skin over the sternum or below
the clavicle is less affected by these age-related changes and provides a more accurate
indication of the client's hydration status.
Question 6
A client reports a sudden, sharp pain in the chest that is worse with a deep breath. During
auscultation, the nurse hears a pleural friction rub. This finding is most consistent with:
A) Pneumonia
B) Asthma
C) Pleurisy
D) Pulmonary edema
E) Emphysema
Correct Answer: C) Pleurisy
Rationale: Pleurisy (pleuritis) is inflammation of the pleura, the membranes that line the
lungs and chest cavity. The inflammation causes the layers to rub against each other during
breathing, resulting in sharp, localized pain (pleuritic pain) and an audible pleural friction
rub.
Question 7
The nurse is testing a client's visual acuity using a Snellen chart. The client's vision is recorded as
20/40. How should the nurse interpret this finding?
A) The client can read at 40 feet what a person with normal vision can read at 20 feet.
B) The client can read at 20 feet what a person with normal vision can read at 40 feet.
C) The client has normal vision.
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D) The client is legally blind.
E) The client needs a referral for a hearing test.
Correct Answer: B) The client can read at 20 feet what a person with normal vision can read
at 40 feet.
Rationale: In the Snellen notation 20/X, the first number (20) represents the distance the
client is standing from the chart (20 feet). The second number represents the distance at
which a person with normal vision could read the same line. Therefore, 20/40 indicates that
the client's vision is worse than normal.
Question 8
A nurse is palpating a client's lymph nodes. Which of the following findings would be most
concerning for a potential malignancy?
A) Soft, mobile, and tender nodes.
B) Small (<1 cm), discrete, and non-tender nodes.
C) A single, hard, non-tender, and fixed node.
D) Multiple, small, and shotty nodes.
E) Tender nodes in the cervical chain with a sore throat.
Correct Answer: C) A single, hard, non-tender, and fixed node.
Rationale: Lymph nodes that are hard, non-tender, and fixed (matted down) to the
underlying tissue are classic warning signs of a potential malignancy. In contrast, nodes
associated with an infection are typically soft, mobile, and tender.
Question 9
During an assessment of the abdomen, the nurse percusses over the majority of the four
quadrants and hears a high-pitched, hollow sound. The nurse should document this sound as:
A) Dullness
B) Flatness
C) Resonance
D) Tympany
E) Hyperresonance
Questions & Answers| Grade A| 100% Correct (Verified Solutions)-
Nightingale
Question 1
The nurse is performing an abdominal assessment on a client. In which sequence should the
nurse perform the assessment techniques?
A) Palpation, percussion, auscultation, inspection
B) Inspection, palpation, percussion, auscultation
C) Auscultation, inspection, palpation, percussion
D) Inspection, auscultation, percussion, palpation
E) Percussion, auscultation, inspection, palpation
Correct Answer: D) Inspection, auscultation, percussion, palpation
Rationale: For an abdominal assessment, the sequence is altered to prevent the stimulation
of bowel sounds that can occur with palpation and percussion. The nurse should first
inspect the abdomen visually, then auscultate for bowel and vascular sounds, and finally
perform percussion and palpation.
Question 2
When assessing a client's pupils for their reaction to light, the nurse notes that both pupils
constrict when a light is shined into the right eye. The nurse should document this finding as a
normal:
A) Pupillary accommodation.
B) Direct and consensual response.
C) Nystagmus.
D) Strabismus.
E) Corneal light reflex.
Correct Answer: B) Direct and consensual response.
Rationale: A normal pupillary light reflex involves both a direct response (the pupil of the
eye with the light constricts) and a consensual response (the pupil of the opposite eye also
constricts simultaneously). This indicates the integrity of the optic nerve (CN II) and the
oculomotor nerve (CN III).
,[Type here]
Question 3
The nurse is assessing a client's level of consciousness. The client opens their eyes when their
name is called, is confused in conversation, and is able to obey a command to raise their arm.
Using the Glasgow Coma Scale (GCS), what score should the nurse assign?
A) 10
B) 11
C) 12
D) 13
E) 14
Correct Answer: D) 13
Rationale: The GCS score is calculated as follows: Eye Opening to speech = 3 points. Verbal
Response is confused = 4 points. Motor Response obeys commands = 6 points. Total Score =
3 + 4 + 6 = 13.
Question 4
While auscultating a client's heart, the nurse hears a low-pitched, scratchy, grating sound at the
apex. The sound is louder when the client is leaning forward. The nurse should suspect which of
the following conditions?
A) Mitral valve stenosis
B) Aortic regurgitation
C) Pericarditis
D) Atrial fibrillation
E) A normal finding
Correct Answer: C) Pericarditis
Rationale: This describes a pericardial friction rub, the hallmark sign of pericarditis
(inflammation of the pericardial sac). It is caused by the inflamed layers of the pericardium
rubbing against each other. Having the client sit up and lean forward brings the heart
closer to the chest wall, often making the rub more audible.
Question 5
A nurse is assessing the skin turgor of a 78-year-old client. Where is the best location to perform
this assessment?
,[Type here]
A) The back of the hand
B) The lower arm
C) Below the clavicle
D) The forehead
E) The palm of the hand
Correct Answer: C) Below the clavicle
Rationale: In older adults, the skin on the hands and arms often loses elasticity due to aging,
making it an unreliable site for assessing skin turgor. The skin over the sternum or below
the clavicle is less affected by these age-related changes and provides a more accurate
indication of the client's hydration status.
Question 6
A client reports a sudden, sharp pain in the chest that is worse with a deep breath. During
auscultation, the nurse hears a pleural friction rub. This finding is most consistent with:
A) Pneumonia
B) Asthma
C) Pleurisy
D) Pulmonary edema
E) Emphysema
Correct Answer: C) Pleurisy
Rationale: Pleurisy (pleuritis) is inflammation of the pleura, the membranes that line the
lungs and chest cavity. The inflammation causes the layers to rub against each other during
breathing, resulting in sharp, localized pain (pleuritic pain) and an audible pleural friction
rub.
Question 7
The nurse is testing a client's visual acuity using a Snellen chart. The client's vision is recorded as
20/40. How should the nurse interpret this finding?
A) The client can read at 40 feet what a person with normal vision can read at 20 feet.
B) The client can read at 20 feet what a person with normal vision can read at 40 feet.
C) The client has normal vision.
, [Type here]
D) The client is legally blind.
E) The client needs a referral for a hearing test.
Correct Answer: B) The client can read at 20 feet what a person with normal vision can read
at 40 feet.
Rationale: In the Snellen notation 20/X, the first number (20) represents the distance the
client is standing from the chart (20 feet). The second number represents the distance at
which a person with normal vision could read the same line. Therefore, 20/40 indicates that
the client's vision is worse than normal.
Question 8
A nurse is palpating a client's lymph nodes. Which of the following findings would be most
concerning for a potential malignancy?
A) Soft, mobile, and tender nodes.
B) Small (<1 cm), discrete, and non-tender nodes.
C) A single, hard, non-tender, and fixed node.
D) Multiple, small, and shotty nodes.
E) Tender nodes in the cervical chain with a sore throat.
Correct Answer: C) A single, hard, non-tender, and fixed node.
Rationale: Lymph nodes that are hard, non-tender, and fixed (matted down) to the
underlying tissue are classic warning signs of a potential malignancy. In contrast, nodes
associated with an infection are typically soft, mobile, and tender.
Question 9
During an assessment of the abdomen, the nurse percusses over the majority of the four
quadrants and hears a high-pitched, hollow sound. The nurse should document this sound as:
A) Dullness
B) Flatness
C) Resonance
D) Tympany
E) Hyperresonance
