BSN 246 EXAM V2: (LATEST 2026/2027
UPDATE) HESI HEALTH ASSESSMENT EXAM
V2, WITH CORRECT/ACCURATE ANSWERS
AT NIGHTINGALE COLLEGE.
BSN 246 EXAM V2 HESI HEALTH
ASSESSMENT
PART 1: Questions 1–25
1. When observing a client’s face, which assessment finding requires the most immediate
nursing intervention?
A. Pallor of the skin
B. Facial asymmetry
C. Oral mucosa is cyanotic
D. Dry lips
Correct Answer: C. Oral mucosa is cyanotic
Rationale: Cyanosis of the oral mucosa indicates inadequate oxygenation and potential respiratory failure.
This is a life-threatening finding requiring immediate intervention, unlike pallor or dryness which are less
urgent.
2. While obtaining a health history, a male client reports occasional shortness of breath.
His respirations are regular and deep at 14 breaths/min. What is the nurse’s best action?
A. Notify the provider
B. Apply supplemental oxygen
C. Ask the client to describe the episodes in more detail
D. Document the finding as normal
Correct Answer: C. Ask the client to describe the episodes in more detail
Rationale: Normal respiratory rate and depth suggest stability. Further subjective data is required to identify
triggers, duration, and severity before intervening.
,3. Which technique should the nurse use to assess a client’s anterior–posterior (AP) chest
diameter?
A. Palpation
B. Percussion
C. Auscultation
D. Observation
Correct Answer: D. Observation
Rationale: The AP diameter is assessed visually by observing the chest contour. Percussion and auscultation
evaluate internal lung sounds, not chest shape.
4. Which assessment finding supports the client’s statement, “My feet swell all the time”?
A. Capillary refill of 4 seconds
B. Cool extremities
C. 2+ pitting edema bilaterally at the ankles
D. Shiny skin on the feet
Correct Answer: C. 2+ pitting edema bilaterally at the ankles
Rationale: Pitting edema confirms fluid accumulation and validates the client’s report of chronic swelling.
5. During a cranial nerve exam on an 87-year-old client, the nurse notes reduced upward
gaze, decreased corneal reflex, high-frequency hearing loss, and reduced gag reflex. What
should the nurse do next?
A. Stop the exam and notify the provider
B. Document findings as abnormal
C. Continue assessment of remaining cranial nerves
D. Perform an emergency neurologic assessment
Correct Answer: C. Continue assessment of remaining cranial nerves
Rationale: These findings are common age-related changes. The nurse should complete the exam before
determining significance.
6. The nurse documents pupils as round, 3 mm, and briskly reactive to light. Which
notation is correct?
A. PERR
B. PERRLA
,C. PERRL
D. PEARL
Correct Answer: C. PERRL
Rationale: PERRL documents pupils equal, round, and reactive to light. Accommodation was not assessed.
7. Which assessment technique provides the best data about peripheral perfusion?
A. Inspection
B. Palpation of pulses
C. Percussion
D. Auscultation
Correct Answer: B. Palpation of pulses
Rationale: Palpating peripheral pulses directly assesses blood flow and perfusion status.
8. A client reports painful, inflamed hemorrhoids. What is the best focused assessment
intervention?
A. Digital rectal exam
B. Supine abdominal palpation
C. Left lateral positioning to inspect perianal area
D. Immediate provider referral
Correct Answer: C. Left lateral positioning to inspect perianal area
Rationale: Visual inspection allows identification of hemorrhoids, fissures, or sacs without causing
unnecessary discomfort.
9. The nurse notes expressionless face, slurred speech, and red conjunctivae. What
question should the nurse ask first?
A. “Have you been drinking alcohol?”
B. “Have you had a recent stroke?”
C. “Have you been sleeping well?”
D. “Are you in pain?”
Correct Answer: C. “Have you been sleeping well?”
Rationale: Sleep deprivation can mimic neurologic or substance-related symptoms. This is the least
accusatory and most appropriate initial question.
, 10. A PN reports a client’s pupils are constricted with minimal response to light. Before
verifying this, what should the nurse do first?
A. Check vital signs
B. Assess visual fields
C. Review medication list
D. Call the provider
Correct Answer: B. Assess visual fields
Rationale: Visual field assessment helps determine neurologic integrity before reassessing pupillary
response.
11. Which abdominal inspection finding is normal in an adult?
A. Visible peristalsis
B. Distended abdomen
C. Homogeneous skin color
D. Bulging umbilicus
Correct Answer: C. Homogeneous skin color
Rationale: Uniform abdominal skin tone is normal. Distension or visible peristalsis may indicate pathology.
12. Which activity best evaluates an older adult’s ability to perform activities of daily living
(ADLs)?
A. Writing a sentence
B. Buttoning a shirt
C. Sorting a collection of socks
D. Reading a paragraph
Correct Answer: C. Sorting a collection of socks
Rationale: This task assesses fine motor skills, coordination, and cognition used in daily living.
13. Which symptoms following a subconjunctival hemorrhage require ophthalmology
referral?
A. Mild eye redness
B. No pain
C. Diminished near focus and increased light requirement
D. Clear drainage
UPDATE) HESI HEALTH ASSESSMENT EXAM
V2, WITH CORRECT/ACCURATE ANSWERS
AT NIGHTINGALE COLLEGE.
BSN 246 EXAM V2 HESI HEALTH
ASSESSMENT
PART 1: Questions 1–25
1. When observing a client’s face, which assessment finding requires the most immediate
nursing intervention?
A. Pallor of the skin
B. Facial asymmetry
C. Oral mucosa is cyanotic
D. Dry lips
Correct Answer: C. Oral mucosa is cyanotic
Rationale: Cyanosis of the oral mucosa indicates inadequate oxygenation and potential respiratory failure.
This is a life-threatening finding requiring immediate intervention, unlike pallor or dryness which are less
urgent.
2. While obtaining a health history, a male client reports occasional shortness of breath.
His respirations are regular and deep at 14 breaths/min. What is the nurse’s best action?
A. Notify the provider
B. Apply supplemental oxygen
C. Ask the client to describe the episodes in more detail
D. Document the finding as normal
Correct Answer: C. Ask the client to describe the episodes in more detail
Rationale: Normal respiratory rate and depth suggest stability. Further subjective data is required to identify
triggers, duration, and severity before intervening.
,3. Which technique should the nurse use to assess a client’s anterior–posterior (AP) chest
diameter?
A. Palpation
B. Percussion
C. Auscultation
D. Observation
Correct Answer: D. Observation
Rationale: The AP diameter is assessed visually by observing the chest contour. Percussion and auscultation
evaluate internal lung sounds, not chest shape.
4. Which assessment finding supports the client’s statement, “My feet swell all the time”?
A. Capillary refill of 4 seconds
B. Cool extremities
C. 2+ pitting edema bilaterally at the ankles
D. Shiny skin on the feet
Correct Answer: C. 2+ pitting edema bilaterally at the ankles
Rationale: Pitting edema confirms fluid accumulation and validates the client’s report of chronic swelling.
5. During a cranial nerve exam on an 87-year-old client, the nurse notes reduced upward
gaze, decreased corneal reflex, high-frequency hearing loss, and reduced gag reflex. What
should the nurse do next?
A. Stop the exam and notify the provider
B. Document findings as abnormal
C. Continue assessment of remaining cranial nerves
D. Perform an emergency neurologic assessment
Correct Answer: C. Continue assessment of remaining cranial nerves
Rationale: These findings are common age-related changes. The nurse should complete the exam before
determining significance.
6. The nurse documents pupils as round, 3 mm, and briskly reactive to light. Which
notation is correct?
A. PERR
B. PERRLA
,C. PERRL
D. PEARL
Correct Answer: C. PERRL
Rationale: PERRL documents pupils equal, round, and reactive to light. Accommodation was not assessed.
7. Which assessment technique provides the best data about peripheral perfusion?
A. Inspection
B. Palpation of pulses
C. Percussion
D. Auscultation
Correct Answer: B. Palpation of pulses
Rationale: Palpating peripheral pulses directly assesses blood flow and perfusion status.
8. A client reports painful, inflamed hemorrhoids. What is the best focused assessment
intervention?
A. Digital rectal exam
B. Supine abdominal palpation
C. Left lateral positioning to inspect perianal area
D. Immediate provider referral
Correct Answer: C. Left lateral positioning to inspect perianal area
Rationale: Visual inspection allows identification of hemorrhoids, fissures, or sacs without causing
unnecessary discomfort.
9. The nurse notes expressionless face, slurred speech, and red conjunctivae. What
question should the nurse ask first?
A. “Have you been drinking alcohol?”
B. “Have you had a recent stroke?”
C. “Have you been sleeping well?”
D. “Are you in pain?”
Correct Answer: C. “Have you been sleeping well?”
Rationale: Sleep deprivation can mimic neurologic or substance-related symptoms. This is the least
accusatory and most appropriate initial question.
, 10. A PN reports a client’s pupils are constricted with minimal response to light. Before
verifying this, what should the nurse do first?
A. Check vital signs
B. Assess visual fields
C. Review medication list
D. Call the provider
Correct Answer: B. Assess visual fields
Rationale: Visual field assessment helps determine neurologic integrity before reassessing pupillary
response.
11. Which abdominal inspection finding is normal in an adult?
A. Visible peristalsis
B. Distended abdomen
C. Homogeneous skin color
D. Bulging umbilicus
Correct Answer: C. Homogeneous skin color
Rationale: Uniform abdominal skin tone is normal. Distension or visible peristalsis may indicate pathology.
12. Which activity best evaluates an older adult’s ability to perform activities of daily living
(ADLs)?
A. Writing a sentence
B. Buttoning a shirt
C. Sorting a collection of socks
D. Reading a paragraph
Correct Answer: C. Sorting a collection of socks
Rationale: This task assesses fine motor skills, coordination, and cognition used in daily living.
13. Which symptoms following a subconjunctival hemorrhage require ophthalmology
referral?
A. Mild eye redness
B. No pain
C. Diminished near focus and increased light requirement
D. Clear drainage
