BSN 246 HESI Health Assessment Exam V3 (Latest 2025/ 2026 Update)
Questions & Answers| Grade A| 100% Correct (Verified Solutions)-
Nightingale
Question 1
A nurse is preparing to perform a physical examination on a client. Which action should the
nurse take first?
A) Auscultate the client's heart and lungs.
B) Obtain the client's vital signs.
C) Perform a general survey.
D) Palpate the client's abdomen.
E) Test the client's deep tendon reflexes.
Correct Answer: C) Perform a general survey.
Rationale: The general survey is the first step in the physical examination and begins the
moment the nurse first encounters the client. It provides an overall impression of the
client's health, including their physical appearance, body structure, mobility, and behavior,
which helps to guide the rest of the assessment.
Question 2
When assessing a client's pulse, the nurse notes that the rhythm is irregular. What is the most
appropriate action for the nurse to take to accurately determine the heart rate?
A) Count the radial pulse for 15 seconds and multiply by 4.
B) Auscultate the apical pulse for a full 60 seconds.
C) Count the carotid pulse for 30 seconds and multiply by 2.
D) Use a Doppler device to count the pedal pulse for one minute.
E) Document the finding and proceed with the assessment.
Correct Answer: B) Auscultate the apical pulse for a full 60 seconds.
Rationale: When a pulse is irregular, counting for a shorter interval and multiplying can
lead to an inaccurate rate. The most accurate method to determine the heart rate in the
presence of an irregular rhythm is to auscultate the apical pulse for a full minute.
Question 3
A nurse is assessing a client's skin turgor. The nurse pinches a fold of skin over the sternum, and
it returns to its original shape slowly. This finding is a sign of:
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A) Fluid volume excess.
B) A normal finding in an older adult.
C) Decreased tissue perfusion.
D) Dehydration.
E) A localized infection.
Correct Answer: D) Dehydration.
Rationale: Skin turgor assesses the skin's elasticity, which is an indicator of hydration
status. Decreased turgor, where the skin remains "tented" or returns slowly to its normal
position, is a classic sign of fluid volume deficit, or dehydration.
Question 4
A nurse is inspecting the pupils of a client and notes that the right pupil is larger than the left
pupil. The nurse should document this finding as:
A) Miosis
B) Mydriasis
C) Nystagmus
D) Anisocoria
E) Strabismus
Correct Answer: D) Anisocoria
Rationale: Anisocoria is the medical term for unequal pupil sizes. While it can be a normal
variation in a small percentage of the population, a new onset of anisocoria can be a sign of
a serious underlying neurological condition.
Question 5
When auscultating a client's lungs, the nurse hears a low-pitched, coarse, snoring sound that is
partially cleared by coughing. This adventitious breath sound is known as:
A) Crackles (rales)
B) Wheezes
C) Rhonchi
D) Stridor
E) A pleural friction rub
,[Type here]
Correct Answer: C) Rhonchi
Rationale: Rhonchi are continuous, low-pitched sounds that have a snoring or rattling
quality. They are caused by the obstruction or movement of secretions in the larger
airways, and a key characteristic is that they often change or clear with coughing.
Question 6
A nurse is assessing a client's orientation. Which of the following questions is the best way to
assess orientation to person?
A) "What is your name?"
B) "Who is the current president?"
C) "Where are you right now?"
D) "What is today's date?"
E) "Do you know why you are here?"
Correct Answer: A) "What is your name?"
Rationale: Orientation is typically assessed in four spheres: person, place, time, and
situation. Assessing orientation to person involves asking the client to state their own name.
Asking about the president assesses fund of knowledge, not orientation to person.
Question 7
The nurse is performing an abdominal assessment. In which of the four quadrants should the
nurse expect to hear the most active bowel sounds?
A) Right upper quadrant (RUQ)
B) Left upper quadrant (LUQ)
C) Right lower quadrant (RLQ)
D) Left lower quadrant (LLQ)
E) Epigastric region
Correct Answer: C) Right lower quadrant (RLQ)
Rationale: The ileocecal valve, which connects the small intestine to the large intestine, is
located in the right lower quadrant. Because the contents of the small intestine are being
emptied into the large intestine at this point, bowel sounds are typically most active and
frequent in the RLQ.
, [Type here]
Question 8
A client's vision is tested with a Snellen chart and is determined to be 20/200 in the better eye
with correction. The nurse should recognize that this client meets the legal definition of:
A) Myopia
B) Presbyopia
C) Legally blind
D) Astigmatism
E) Normal vision
Correct Answer: C) Legally blind
Rationale: Legal blindness in the United States is defined as a best-corrected visual acuity of
20/200 or worse in the better eye, or a visual field of 20 degrees or less. This client's visual
acuity meets this criterion.
Question 9
When assessing the six cardinal positions of gaze, the nurse is evaluating:
A) Visual acuity.
B) Peripheral vision.
C) Pupillary reaction to light.
D) The function of the extraocular muscles and cranial nerves III, IV, and VI.
E) The internal structures of the eye.
Correct Answer: D) The function of the extraocular muscles and cranial nerves III, IV, and
VI.
Rationale: This test assesses the client's ability to move their eyes in a coordinated fashion
through different fields of gaze. This movement is controlled by the six extraocular muscles,
which are innervated by the oculomotor (III), trochlear (IV), and abducens (VI) cranial
nerves.
Question 10
A nurse is assessing a client with a history of heart failure. The nurse notes that the client has
swelling in their feet and ankles that leaves an indentation when pressed. The nurse should
document this finding as:
A) Non-pitting edema
Questions & Answers| Grade A| 100% Correct (Verified Solutions)-
Nightingale
Question 1
A nurse is preparing to perform a physical examination on a client. Which action should the
nurse take first?
A) Auscultate the client's heart and lungs.
B) Obtain the client's vital signs.
C) Perform a general survey.
D) Palpate the client's abdomen.
E) Test the client's deep tendon reflexes.
Correct Answer: C) Perform a general survey.
Rationale: The general survey is the first step in the physical examination and begins the
moment the nurse first encounters the client. It provides an overall impression of the
client's health, including their physical appearance, body structure, mobility, and behavior,
which helps to guide the rest of the assessment.
Question 2
When assessing a client's pulse, the nurse notes that the rhythm is irregular. What is the most
appropriate action for the nurse to take to accurately determine the heart rate?
A) Count the radial pulse for 15 seconds and multiply by 4.
B) Auscultate the apical pulse for a full 60 seconds.
C) Count the carotid pulse for 30 seconds and multiply by 2.
D) Use a Doppler device to count the pedal pulse for one minute.
E) Document the finding and proceed with the assessment.
Correct Answer: B) Auscultate the apical pulse for a full 60 seconds.
Rationale: When a pulse is irregular, counting for a shorter interval and multiplying can
lead to an inaccurate rate. The most accurate method to determine the heart rate in the
presence of an irregular rhythm is to auscultate the apical pulse for a full minute.
Question 3
A nurse is assessing a client's skin turgor. The nurse pinches a fold of skin over the sternum, and
it returns to its original shape slowly. This finding is a sign of:
,[Type here]
A) Fluid volume excess.
B) A normal finding in an older adult.
C) Decreased tissue perfusion.
D) Dehydration.
E) A localized infection.
Correct Answer: D) Dehydration.
Rationale: Skin turgor assesses the skin's elasticity, which is an indicator of hydration
status. Decreased turgor, where the skin remains "tented" or returns slowly to its normal
position, is a classic sign of fluid volume deficit, or dehydration.
Question 4
A nurse is inspecting the pupils of a client and notes that the right pupil is larger than the left
pupil. The nurse should document this finding as:
A) Miosis
B) Mydriasis
C) Nystagmus
D) Anisocoria
E) Strabismus
Correct Answer: D) Anisocoria
Rationale: Anisocoria is the medical term for unequal pupil sizes. While it can be a normal
variation in a small percentage of the population, a new onset of anisocoria can be a sign of
a serious underlying neurological condition.
Question 5
When auscultating a client's lungs, the nurse hears a low-pitched, coarse, snoring sound that is
partially cleared by coughing. This adventitious breath sound is known as:
A) Crackles (rales)
B) Wheezes
C) Rhonchi
D) Stridor
E) A pleural friction rub
,[Type here]
Correct Answer: C) Rhonchi
Rationale: Rhonchi are continuous, low-pitched sounds that have a snoring or rattling
quality. They are caused by the obstruction or movement of secretions in the larger
airways, and a key characteristic is that they often change or clear with coughing.
Question 6
A nurse is assessing a client's orientation. Which of the following questions is the best way to
assess orientation to person?
A) "What is your name?"
B) "Who is the current president?"
C) "Where are you right now?"
D) "What is today's date?"
E) "Do you know why you are here?"
Correct Answer: A) "What is your name?"
Rationale: Orientation is typically assessed in four spheres: person, place, time, and
situation. Assessing orientation to person involves asking the client to state their own name.
Asking about the president assesses fund of knowledge, not orientation to person.
Question 7
The nurse is performing an abdominal assessment. In which of the four quadrants should the
nurse expect to hear the most active bowel sounds?
A) Right upper quadrant (RUQ)
B) Left upper quadrant (LUQ)
C) Right lower quadrant (RLQ)
D) Left lower quadrant (LLQ)
E) Epigastric region
Correct Answer: C) Right lower quadrant (RLQ)
Rationale: The ileocecal valve, which connects the small intestine to the large intestine, is
located in the right lower quadrant. Because the contents of the small intestine are being
emptied into the large intestine at this point, bowel sounds are typically most active and
frequent in the RLQ.
, [Type here]
Question 8
A client's vision is tested with a Snellen chart and is determined to be 20/200 in the better eye
with correction. The nurse should recognize that this client meets the legal definition of:
A) Myopia
B) Presbyopia
C) Legally blind
D) Astigmatism
E) Normal vision
Correct Answer: C) Legally blind
Rationale: Legal blindness in the United States is defined as a best-corrected visual acuity of
20/200 or worse in the better eye, or a visual field of 20 degrees or less. This client's visual
acuity meets this criterion.
Question 9
When assessing the six cardinal positions of gaze, the nurse is evaluating:
A) Visual acuity.
B) Peripheral vision.
C) Pupillary reaction to light.
D) The function of the extraocular muscles and cranial nerves III, IV, and VI.
E) The internal structures of the eye.
Correct Answer: D) The function of the extraocular muscles and cranial nerves III, IV, and
VI.
Rationale: This test assesses the client's ability to move their eyes in a coordinated fashion
through different fields of gaze. This movement is controlled by the six extraocular muscles,
which are innervated by the oculomotor (III), trochlear (IV), and abducens (VI) cranial
nerves.
Question 10
A nurse is assessing a client with a history of heart failure. The nurse notes that the client has
swelling in their feet and ankles that leaves an indentation when pressed. The nurse should
document this finding as:
A) Non-pitting edema
