BSN 246 HESI HEALTH ASSESSMENT
V1/ACTUAL EXAM – NIGHTINGALE
COLLEGE. EXAM QUESTIONS AND
ANSWERS GRADED A+ 2025/2026
The nurse is performing a thoracic assessment on a client with chronic asthma and
hyperinflation of the lungs. Which finding should be expected for this client? - ANS Barrel
chest
The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard bowel sounds
in the right upper quadrant. What action should the nurse take next? - ANS Note the
character and frequency of bowel sounds
During inspection of a client's mouth and pharynx, the nurse places a tongue blade on the back
of the tongue which causes the client to gag. After removing the tongue blade, what action
should the nurse take? - ANS Document an intact gag reflex.
When teaching a client how to perform a monthly breast self-assessment, the nurse should tell
the client that it is most important to assess which part of the breast more closely for changes?
- ANS Upper outer quadrant.
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,The nurse is assessing a postmenopausal client who has a BMI of 32. The client has a chest
measurement of 42 inches, waist measurement of 45 inches, and hip measurement of 50
inches. What important message should the nurse explain to the client to promote health
promotion? - ANS A waist circumference is greater than 35 inches in women puts you at
higher risk for type 2 diabetes and heart disease."
The nurse performs a physical assessment on an older female client. Which change from the
prior exam may be an indication of osteoporosis? - ANS Height reduction of 1.5 inches.
While conducting an interview to obtain a health history, the nurse notices that the client
pauses frequently and looks at the nurse expectantly. Which response is best for the nurse to
provide? - ANS Sit quietly to allow the client to respond comfortably.
A client is in the clinical for a yearly physical examination. Which action should the nurse take
when preparing to examine the client's abdomen? - ANS Ask the client to urinate before
beginning the examination.
Which respiratory condition should the nurse document after measuring a respiratory rate of 8
breaths/minute? - ANS Bradypnea.
Which procedure should the nurse use to assessfor a pulse deficit? - ANS Measure the apical
pulse and compare it to the peripheral pulse.
*A pulse deficit is a palpable difference between the apical pulse at the point of maximal
impulse and the radial pulse palpated at the wrist.
A client has been diagnosed with bilateral lower lobe atelectasis. What percussion sound should
the nurse expect to hear when percussing over the client's lower lobes? - ANS Dull, thud-like.
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, A client is being assessed upon admission to the medical-surgical unit. The nurse is preparing to
complete a head-to-toe assessment and will begin at the head of the client. Which technique
should the nurse use to begin the assessment? - ANS Inspect the hair and skin.
The nurse is assessing a healthy young adult during an annual physical examination. Which
assessment technique should the nurse implement when palpating the abdominal aorta? -
ANS Deep palpation above and to the left of the umbilicus.
The nurse is conducting a family history as part of the assessment interview. Which action
should the nurse take to ensure that sufficient information about the client's blood relatives is
obtained? - ANS Document at least 3 generations of the client's family medical history.
The nurse is testing the client's shoulders for range of motion. What should the nurse document
to record normal internal rotation? - ANS Range of 90 degrees when the hands are placed at
the small of the back.
A client presents with a rash along the occipital area of the hairline and reports intense itching.
How should the nurse begin the objective part of the examination? - ANS Inspect the scalp
looking for nits.
The nurse is assessing a client's range of motion as the client bends the right knee up to the
chest while keeping the left leg straight, but is unable to keep the left thigh on the table. The
assessment is repeated for the left knee, and the client is unable to keep the right thigh on the
table. How should the nurse document this finding? - ANS A flexion deformity referred to as a
positive Thomas test.
During a skin asssessment, the nurse notes, round and discrete lesions that are dark red in color
and will not blanch. The lesions range from 1 to 3 mm in size. What is the first question the
nurse should ask the client? - ANS Have you notice any irregular bleeding
3 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
V1/ACTUAL EXAM – NIGHTINGALE
COLLEGE. EXAM QUESTIONS AND
ANSWERS GRADED A+ 2025/2026
The nurse is performing a thoracic assessment on a client with chronic asthma and
hyperinflation of the lungs. Which finding should be expected for this client? - ANS Barrel
chest
The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard bowel sounds
in the right upper quadrant. What action should the nurse take next? - ANS Note the
character and frequency of bowel sounds
During inspection of a client's mouth and pharynx, the nurse places a tongue blade on the back
of the tongue which causes the client to gag. After removing the tongue blade, what action
should the nurse take? - ANS Document an intact gag reflex.
When teaching a client how to perform a monthly breast self-assessment, the nurse should tell
the client that it is most important to assess which part of the breast more closely for changes?
- ANS Upper outer quadrant.
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,The nurse is assessing a postmenopausal client who has a BMI of 32. The client has a chest
measurement of 42 inches, waist measurement of 45 inches, and hip measurement of 50
inches. What important message should the nurse explain to the client to promote health
promotion? - ANS A waist circumference is greater than 35 inches in women puts you at
higher risk for type 2 diabetes and heart disease."
The nurse performs a physical assessment on an older female client. Which change from the
prior exam may be an indication of osteoporosis? - ANS Height reduction of 1.5 inches.
While conducting an interview to obtain a health history, the nurse notices that the client
pauses frequently and looks at the nurse expectantly. Which response is best for the nurse to
provide? - ANS Sit quietly to allow the client to respond comfortably.
A client is in the clinical for a yearly physical examination. Which action should the nurse take
when preparing to examine the client's abdomen? - ANS Ask the client to urinate before
beginning the examination.
Which respiratory condition should the nurse document after measuring a respiratory rate of 8
breaths/minute? - ANS Bradypnea.
Which procedure should the nurse use to assessfor a pulse deficit? - ANS Measure the apical
pulse and compare it to the peripheral pulse.
*A pulse deficit is a palpable difference between the apical pulse at the point of maximal
impulse and the radial pulse palpated at the wrist.
A client has been diagnosed with bilateral lower lobe atelectasis. What percussion sound should
the nurse expect to hear when percussing over the client's lower lobes? - ANS Dull, thud-like.
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, A client is being assessed upon admission to the medical-surgical unit. The nurse is preparing to
complete a head-to-toe assessment and will begin at the head of the client. Which technique
should the nurse use to begin the assessment? - ANS Inspect the hair and skin.
The nurse is assessing a healthy young adult during an annual physical examination. Which
assessment technique should the nurse implement when palpating the abdominal aorta? -
ANS Deep palpation above and to the left of the umbilicus.
The nurse is conducting a family history as part of the assessment interview. Which action
should the nurse take to ensure that sufficient information about the client's blood relatives is
obtained? - ANS Document at least 3 generations of the client's family medical history.
The nurse is testing the client's shoulders for range of motion. What should the nurse document
to record normal internal rotation? - ANS Range of 90 degrees when the hands are placed at
the small of the back.
A client presents with a rash along the occipital area of the hairline and reports intense itching.
How should the nurse begin the objective part of the examination? - ANS Inspect the scalp
looking for nits.
The nurse is assessing a client's range of motion as the client bends the right knee up to the
chest while keeping the left leg straight, but is unable to keep the left thigh on the table. The
assessment is repeated for the left knee, and the client is unable to keep the right thigh on the
table. How should the nurse document this finding? - ANS A flexion deformity referred to as a
positive Thomas test.
During a skin asssessment, the nurse notes, round and discrete lesions that are dark red in color
and will not blanch. The lesions range from 1 to 3 mm in size. What is the first question the
nurse should ask the client? - ANS Have you notice any irregular bleeding
3 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
