ESTUDYR
NSG 121 HEALTH ASSESSMENT HESI FINAL EXAM, HESI 1 AND 2
REMEDIATION PACKAGES, NSG 261 FINAL HESI- Q&A
Nursing Assessment & Practice HESI
1. When obtaining a nursing history from a new patient, which technique should the nurse
use to allow the patient the widest range of possible responses?
A. Closed-ended questions
B. Direct, focused questions
C. Open-ended questions D. Leading questions
Rationale: Open-ended questions allow patients to respond in their own words and provide
more detail, rather than a simple "yes" or "no," which is essential for a comprehensive nursing
history.
2. A patient is being assessed for potential substance abuse. The nurse uses the CAGE
questionnaire. What does a score of 2 or more indicate?
A. The patient is in recovery
B. The patient has no history of abuse
C. A potential problem with drugs or alcohol D. The patient requires immediate detox
Rationale: The CAGE questionnaire (Cut down, Annoyed, Guilty, Eye-opener) is a self-report
tool. A score of "yes" to two or more questions indicates a potential substance use problem.
3. During a physical assessment, the nurse notes "tenting" after pinching a fold of skin below
the patient's clavicle. How should the nurse document this finding?
A. Normal skin elasticity
B. Age-related thinning
C. Dehydration (poor skin turgor) D. Stage 1 pressure injury
Rationale: Tenting (when skin stays pinched and does not immediately return to its original
position) is a classic sign of dehydration or poor skin turgor.
,ESTUDYR
4. While assessing a patient with chronic hypoxia due to Emphysema, the nurse observes the
angle of the nail to the finger is greater than 160°. What is this finding called?
A. Koilonychia
B. Paronychia
C. Clubbing D. Beau’s lines
Rationale: Clubbing of the nails is a sign of chronic hypoxia, often seen in conditions like
Emphysema or Congestive Heart Failure.
5. A nurse is performing a Weber and Rinne test. The patient's Bone Conduction (BC) is longer
than or equal to Air Conduction (AC). This indicates:
A. Sensorineural hearing loss
B. Conductive hearing loss C. Normal hearing
D. Tinnitus
Rationale: In a normal ear, AC should be longer than BC. When BC is equal to or longer than AC,
it is evidence of conductive hearing loss, possibly due to external or middle ear disease.
6. The nurse is scoring a newborn at 1 minute and 5 minutes using the APGAR scale. A score
of 3 indicates:
A. Vigorous newborn adapting well
B. Moderately depressed
C. Severe respiratory depression D. Normal transition to extrauterine life
Rationale: An APGAR score of 7–10 is normal; 4–6 is moderately depressed; and 0–3 indicates
severe respiratory depression requiring NICU care.
7. A patient is unable to move their leg against gravity but can complete a full Range of
Motion (ROM) when the joint is supported on the bed. How should the nurse grade this
muscle strength?
A. 1/5
B. 2/5 C. 3/5
D. 4/5
, ESTUDYR
Rationale: Muscle strength is graded as 2/5 when the patient has complete ROM with the joint
supported but cannot perform the movement against gravity.
8. The nurse is auscultating the heart and hears S2 louder than S1. In which areas is this sound
typically the loudest?
A. Aortic and Pulmonic areas B. Tricuspid and Mitral areas
C. Erb's point
D. The epigastrum
Rationale: S2 (the "Dub") is louder at the base of the heart (Aortic and Pulmonic areas),
while S1 (the "Lub") is louder at the apex (Tricuspid and Mitral areas).
9. Which action is the priority for a nurse when a pulse oximeter alarms and displays 80%
saturation on a patient who appears comfortable and pink?
A. Increase oxygen to 10 liters
B. Call a Code Blue
C. Check that the placement of the pulse oximeter is correct D. Notify the physician
immediately
Rationale: If the patient's clinical presentation (pink mucous membranes, unlabored breathing)
does not match the alarm, the nurse should first verify the equipment and placement.
10. A patient has just returned from a cardiac catheterization. The nurse notes the patient is
reporting discomfort at the femoral insertion site. According to standing orders, what should
the nurse do?
A. Apply a cold pack for 45 minutes
B. Perform a bladder scan
C. Administer acetaminophen/codeine phosphate D. Encourage the patient to walk
Rationale: For reported discomfort following a cardiac catheterization, the standing order is to
provide pharmacological pain relief as prescribed.
11. Which action should the nurse prioritize when communicating with a patient who does
not speak English? A. Speak loudly and slowly in English B. Use a family member to translate
C. Use a professional interpreter whenever possible D. Use hand gestures and pictures only
NSG 121 HEALTH ASSESSMENT HESI FINAL EXAM, HESI 1 AND 2
REMEDIATION PACKAGES, NSG 261 FINAL HESI- Q&A
Nursing Assessment & Practice HESI
1. When obtaining a nursing history from a new patient, which technique should the nurse
use to allow the patient the widest range of possible responses?
A. Closed-ended questions
B. Direct, focused questions
C. Open-ended questions D. Leading questions
Rationale: Open-ended questions allow patients to respond in their own words and provide
more detail, rather than a simple "yes" or "no," which is essential for a comprehensive nursing
history.
2. A patient is being assessed for potential substance abuse. The nurse uses the CAGE
questionnaire. What does a score of 2 or more indicate?
A. The patient is in recovery
B. The patient has no history of abuse
C. A potential problem with drugs or alcohol D. The patient requires immediate detox
Rationale: The CAGE questionnaire (Cut down, Annoyed, Guilty, Eye-opener) is a self-report
tool. A score of "yes" to two or more questions indicates a potential substance use problem.
3. During a physical assessment, the nurse notes "tenting" after pinching a fold of skin below
the patient's clavicle. How should the nurse document this finding?
A. Normal skin elasticity
B. Age-related thinning
C. Dehydration (poor skin turgor) D. Stage 1 pressure injury
Rationale: Tenting (when skin stays pinched and does not immediately return to its original
position) is a classic sign of dehydration or poor skin turgor.
,ESTUDYR
4. While assessing a patient with chronic hypoxia due to Emphysema, the nurse observes the
angle of the nail to the finger is greater than 160°. What is this finding called?
A. Koilonychia
B. Paronychia
C. Clubbing D. Beau’s lines
Rationale: Clubbing of the nails is a sign of chronic hypoxia, often seen in conditions like
Emphysema or Congestive Heart Failure.
5. A nurse is performing a Weber and Rinne test. The patient's Bone Conduction (BC) is longer
than or equal to Air Conduction (AC). This indicates:
A. Sensorineural hearing loss
B. Conductive hearing loss C. Normal hearing
D. Tinnitus
Rationale: In a normal ear, AC should be longer than BC. When BC is equal to or longer than AC,
it is evidence of conductive hearing loss, possibly due to external or middle ear disease.
6. The nurse is scoring a newborn at 1 minute and 5 minutes using the APGAR scale. A score
of 3 indicates:
A. Vigorous newborn adapting well
B. Moderately depressed
C. Severe respiratory depression D. Normal transition to extrauterine life
Rationale: An APGAR score of 7–10 is normal; 4–6 is moderately depressed; and 0–3 indicates
severe respiratory depression requiring NICU care.
7. A patient is unable to move their leg against gravity but can complete a full Range of
Motion (ROM) when the joint is supported on the bed. How should the nurse grade this
muscle strength?
A. 1/5
B. 2/5 C. 3/5
D. 4/5
, ESTUDYR
Rationale: Muscle strength is graded as 2/5 when the patient has complete ROM with the joint
supported but cannot perform the movement against gravity.
8. The nurse is auscultating the heart and hears S2 louder than S1. In which areas is this sound
typically the loudest?
A. Aortic and Pulmonic areas B. Tricuspid and Mitral areas
C. Erb's point
D. The epigastrum
Rationale: S2 (the "Dub") is louder at the base of the heart (Aortic and Pulmonic areas),
while S1 (the "Lub") is louder at the apex (Tricuspid and Mitral areas).
9. Which action is the priority for a nurse when a pulse oximeter alarms and displays 80%
saturation on a patient who appears comfortable and pink?
A. Increase oxygen to 10 liters
B. Call a Code Blue
C. Check that the placement of the pulse oximeter is correct D. Notify the physician
immediately
Rationale: If the patient's clinical presentation (pink mucous membranes, unlabored breathing)
does not match the alarm, the nurse should first verify the equipment and placement.
10. A patient has just returned from a cardiac catheterization. The nurse notes the patient is
reporting discomfort at the femoral insertion site. According to standing orders, what should
the nurse do?
A. Apply a cold pack for 45 minutes
B. Perform a bladder scan
C. Administer acetaminophen/codeine phosphate D. Encourage the patient to walk
Rationale: For reported discomfort following a cardiac catheterization, the standing order is to
provide pharmacological pain relief as prescribed.
11. Which action should the nurse prioritize when communicating with a patient who does
not speak English? A. Speak loudly and slowly in English B. Use a family member to translate
C. Use a professional interpreter whenever possible D. Use hand gestures and pictures only
