Download BSN 246 HESI HEALTH ASSESSMENT UPDATED EXAM 2024/2025 and more Exams Nursing in PDF only on Docsity!
BSN 246 HESI HEALTH ASSESSMENT UPDATED EXAM 2024/
QUESTIONS AND VERIFIED 100% CORRECT ANSWERS
“Which action can be assigned to the unlicensed assistive personnel (UAP)? - CORRECT
ANSWER Measure the client's urinary output."
"The nurse prepares and instructs the client for hemodialysis. Which statements by the client indicate the need for further education? (Select all that apply. One, some, or all options may be
correct.) - CORRECT ANSWER Hemodialysis will help restore kidney function back to a
normal level. - Bowel or bladder perforation may occur with hemodialysis catheter placement." "What action should the nurse take based on the response from the healthcare provider (HCP)
phone call? (Select all that apply. One, some, or all options may be correct.) - CORRECT
ANSWER Document both phone calls and the HCP's prescriptions. - Notify the charge nurse
and activate the chain of command - Hold the potassium chloride"
"Which intervention should the nurse implement? - CORRECT ANSWER Call and speak
directly with the healthcare provider (HCP)." "The registered nurse (RN) uses the mini-mental state examination (MMSE) when assessing a client for admission to an assisted living facility. Which finding is the RN assessing when requesting the client to count by 7s? A. Recall of information. B. Orientation to surroundings. C. Attention to details.
D. Ability to follow complex commands. - CORRECT ANSWER C"
"The registered nurse (RN) palpates a weak pedal pulse in the client's right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation? (Select all that apply.) A. Diminished hair on legs. B. Bruising on extremities. C. Skin cool to touch. D. Capillary refill less than 3 seconds.
E. Darkened skin on extremities. - CORRECT ANSWER A, C"
"Which action should the registered nurse (RN) implement to complete an assessment for a client while using an interpreter? A. Ask closed-ended questions with the assistance of the interpreter. B. Maintain eye contact with the client while listening to the translation.
C. Instruct interpreter to answer questions from interpreter's point of view.
D. Protect the client's privacy by asking a limited number of questions. - CORRECT ANSWER
B"
"A client with progressive hearing loss appears distressed when the registered nurse (RN) asks open-ended questions about the client's health history. Which forms of communication should the RN use? (Select all that apply.) A. Face the client so the client can see the RN's mouth. B. Increase one's speech volume when interacting with the client. C. Repeat information to the client if misunderstood. D. Check if the client's hearing aides are working properly.
E. Reduce environmental noise surrounding the client. - CORRECT ANSWER A, D, E"
"A client is newly diagnosed with diverticulosis. The registered nurse (RN) is assessing the client's basic knowledge about the disease process. Which statement by the client conveys the client's understanding of the etiology of diverticula? A. Over use of laxatives for bowel regularity result in loss of peristaltic tone. B. Inflammation of the colon mucosa cause growths that protrude into the colon lumen. C. Diverticulosis is the result of high fiber diet and sedentary life style.
D. Chronic constipation causes weakening of colon wall which result in out-pouching sacs. -
CORRECT ANSWER D"
"The registered nurse (RN) is teaching a client who is being discharged after treatment of tuberculosis (TB). Which cultural issues should the RN assess when preparing the client for discharge? (Select all that apply.) A. Native language. B. Education level. C. Type of lifestyle. D. Previous medical history.
E. Financial resources. - CORRECT ANSWER A, B, C, D"
"A female client is recently diagnosed with Sarcoidosis. The client tells the registered nurse (RN) that she does not understand why she has this. When teaching about the occurrence of sarcoidosis, the RN should include that sarcoidosis most commonly occurs with which ethnic group of women? A. African American women. B. Caucasian women. C. Asian women.
D. Hispanic women. - CORRECT ANSWER A"
D. The treatment time is decreased from 6 months to 3 months with this standard regimen. -
CORRECT ANSWER A"
"The registered nurse (RN) is caring for an older client who recently experienced a fractured pelvis from a fall. Which assessment finding is most important for the RN to report the healthcare provider? A. Lower back pain. B. Headache of 7 on scale 1 to 10. C. Blood pressure of 140/98.
D. Dyspnea. - CORRECT ANSWER D"
"The registered nurse (RN) is caring for a young adult who is having an oral glucose tolerance tests (OGTT). Which laboratory result should the RN assess as a normal value for the two hour postprandial result? A. 140 mg/dl. B. 160 mg/dl. C. 180 mg/dl.
D. 200 mg/dl. - CORRECT ANSWER A"
"The registered nurse (RN) is teaching a client who is being discharged after treatment of tuberculosis (TB). Which cultural issues should the RN assess when preparing the client for discharge? (Select all that apply.) Native language. Education level. Type of lifestyle. Financial resources.
Previous medical history. - CORRECT ANSWER Native language.
Education level. Type of lifestyle." "The registered nurse (RN) is caring for an older client who has been bedridden for two weeks. Which assessment findings indicate to the RN that the client is developing a complication related to immobility? Decreased pedal pulses.
Edema in upper extremities. Loss of appetite for food.
Stiffness in right ankle joint. - CORRECT ANSWER Stiffness in right ankle joint"
"The registered nurse (RN) places an ice pack on a middle school student who comes to the school clinic complaining of a sprained ankle. Which therapeutic response should the RN anticipate? Reduced pain and minimized brusing. Lowering of body core temperature. Increased circulation around injury.
Reabsorption of edema at injury. - CORRECT ANSWER Reduced pain and minimized
bruising" "The registered nurse (RN) is caring for a client with tuberculosis (TB) who is taking a combination drug regimen. The client complains about taking "so many pills." What information should the RN provide to the client about the prescribed treatement? The development of resistant strains of TB are decreased with a combination of drugs. Compliance to the medication regimen is challenging but should be maintained. Side effects are minimized with the use of a single medication but is less effective.
The treatment time is decreased from 6 months to 3 months with this standard regimen. -
CORRECT ANSWER The development of resistant strains of TB are decreased with a
combination of drugs." "The registered nurse (RN) is caring for a client who has taken atenolol for 2 years. The healthcare provider recently changed the medication to enalaprilto manage the client's blood pressure. Which instruction should the RN provide the client regarding the new medication? Take the medication at bedtime. Report presence of increased bruising. Check pulse before taking medication.
"A client is admitted for dehydration, weight loss, and a flat affect. After reviewing the client's history, the registered nurse (RN) discovers that the client's spouse died 2 weeks ago. Which nursing interventions should the RN implement to help the client begin the process of dealing with loss? Select all that apply Establish trust by creating an safe atmosphere for sharing. Share personal stories about how other clients dealt with grief. Help the client identify ways to adapt lifestyle to accommodate loss. Assure the client that their grief will last a short period of time.
Explore ways to assist the client to make new emotional investments. - CORRECT ANSWER
Establish trust by creating an safe atmosphere for sharing. Help the client identify ways to adapt lifestyle to accommodate loss. Explore ways to assist the client to make new emotional investments." "A client with cirrhosis of the liver asks the registered nurse (RN) to explain how varicose veins can occur in the esophagus. Which statement should the RN provide to teach the client about the physiological etiology? A. The enlarged liver presses on the lower half of the esophagus which weakens blood vessel walls. B. Abnormal vessels form as a result of liver damage that causes chronic low serum protein levels. C. Esophageal swelling and tissue damage causes blood to circulate blood back through the stomach. D. Increased portal pressure causes blood flow through liver to be shunted to the esophageal
vessels. - CORRECT ANSWER D. Increased portal pressure causes blood flow through liver to
be shunted to the esophageal vessels." "The registered nurse (RN) reviews the new prescription, phenelzine (Nardil), a monoamine oxidase inhibitor (MAOI), for a client on the psychiatric unit with depression. Which information is most important for the RN to assess? Consumptiion of any alcohol or tyramine-rich foods. Complaints of nausea or vomiting. Therapeutic serum drug levels.
Blood pressure and pulse prior to taking each dose.Consumptiion of any alcohol or tyramine-rich
foods. - CORRECT ANSWER Consumptiion of any alcohol or tyramine-rich foods."
"A client with progressive hearing loss appears distressed when the registered nurse (RN) asks open-ended questions about the client's health history. Which forms of communication should the RN use? Select all that apply Face the client so the client can see the RN's mouth. Increase one's speech volume when interacting with the client. Repeat information to the client if misunderstood. Check if the client's hearing aides are working properly.
Reduce environmental noise surrounding the client. - CORRECT ANSWER Face the client so
the client can see the RN's mouth. Check if the client's hearing aides are working properly. Reduce environmental noise surrounding the client." "The registered nurse (RN) is making early morning rounds on a group of clients when a client begins exhibiting symptoms of an acute asthma attack. The RN administers a PRN prescription for a Beta 2 receptor agonist agent. Which client response should the RN expect? Select all that apply Tachycardia. Increased blood pressure. Rapid resolution of wheezing. Improved pulse oximetry values.
Reduce fever airway inflammation. - CORRECT ANSWER Rapid resolution of wheezing
Improved pulse ox values" "The registered nurse (RN) is caring for a client with a newly placed nasogastric tube (NGT). Once the placement of the NG tube is verified by x-ray, which technique should the RN use as a reliable method to ensure the NGT is not displaced? Check pH of aspirated stomach contents obtained from the NGT.
"The registered nurse (RN) is caring for a client who has taken atenolol for 2 years. The healthcare provider recently changed the medication to enalaprilto manage the client's blood pressure. Which instruction should the RN provide the client regarding the new medication? -Take the medication at bedtime. -Report presence of increased bruising. -Check pulse before taking medication.
-Rise slowly when getting out of bed or chair. - CORRECT ANSWER D"
"The registered nurse (RN) is making early morning rounds on a group of clients when a client begins exhibiting symptoms of an acute asthma attack. The RN administers a PRN prescription for a Beta 2 receptor agonist agent. Which client response should the RN expect? Select all that apply -Tachycardia. -Increased blood pressure. -Rapid resolution of wheezing. -Improved pulse oximetry values.
-Reduce fever airway inflammation. - CORRECT ANSWER Rapid resolution of wheezing
Improved pulse ox values" "The registered nurse (RN) is evaluating a client who presents with symptoms of viral gastroenteritis. Which assessment finding should the RN report to the healthcare provider? -Dry mucous membranes and lips. -Rebound abdominal tenderness over right lower quadrant. -Dizziness when client ambulates from a sitting position.
-Poor skin turgor over client's wrist. - CORRECT ANSWER Rebound abdominal tenderness
over right lower quadrant" "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? - CORRECT
ANSWER 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? - CORRECT ANSWER
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? - CORRECT ANSWER Document an intact gag reflex"
"A client is reporting chest pain. What statement made by the client, helps the nurse to
understand this client has a naturalistic belief in the cause of illness? - CORRECT ANSWER
"My life is really out of balance."" "The nurse is preparing to assess the hearing of a client with a history of prolonged exposure to occupational noise. Which hearing test provides the most reliable assessment of hearing status?
CORRECT ANSWER Audiometry"
"The nurse is performing a routine physical examination on an adult client. When gathering a
health history, which question is included in the CAGE questionnaire? - CORRECT ANSWER
"Have you ever felt guilty about your drinking?"" "The nurse is examining the hip joint of a client who reports hip pain. Which other assessment is
most helpful in determining the cause of the client's pain? - CORRECT ANSWER Knee-joint
eval" "The nurse performs a series of cranial nerve tests on a client with a head injury. Which test
should the nurse use to assess damage to the first cranial nerve? - CORRECT ANSWER
Occlude one nostril and have the client identify various odors." "The client reports to the nurse a recent exposure to the mumps. Which assessment finding
suggests the client has contracted the mumps? - CORRECT ANSWER Swelling anterior to the
ear lobe on one side of the face" "A nurse is working in a healthcare facility that serves a diverse population. What action(s) by the nurse will allow the nurse to empathize with and understand this population? (Select all that
apply.) - CORRECT ANSWER Be open to people who are different.
Have a curiosity about people. Become culturally competent."
"Which findings can the nurse determine by palpating a client's skin? (Select all that apply.) -
CORRECT ANSWER Diaphoresis
Scaling"
"Which question should the nurse ask in order to test a client's remote memory? - CORRECT
ANSWER What is your date of birth?"
"While assessing level of consciousness, the nurse finds that a client localizes to pain, is confused during conversation, and opens the eyes to sound. How should the nurse document the Glasgow
score of this client? - CORRECT ANSWER 12"
"A client is in the clinic for a routine health examination. The nurse notices the client appears underweight. Which question is most important for the nurse to ask when completing the health
history of this client? - CORRECT ANSWER Have you experienced sudden weight loss?"
"A male executive is seen in the primary care clinic for a physical examination. While obtaining the client's health history, the nurse inquires about his drug and alcohol use. The executive denies drug use, but reports that he has "two glasses of wine" per night. Which response is best
for the nurse to provide? - CORRECT ANSWER "What effect do you think your alcohol may
have on you?"" "Which part of the body should the nurse examine when assessing for peripheral edema in a
client with heart failure? - CORRECT ANSWER Ankles"
"A client reports feeling increasingly fatigued for several months, and the nurse observes that the client's lips are pale. Which additional data should the nurse collect based on this presentation?
CORRECT ANSWER Use of iron and vitamin supplements"
"What is the best place for the nurse to hear lower lobe lung sounds with a stethoscope? -
CORRECT ANSWER Posterior chest below the 3rd intercostal space"
"The nurse is assessing the posterior pharynx during a physical examination. Which technique
should the nurse use? - CORRECT ANSWER Press the tongue down one side at a time with a
tongue depressor." "The nurse is assessing a client who has a history of mitral stenosis. How should the nurse assess
this client with a stethoscope to listen for this condition? - CORRECT ANSWER Place the bell
on the 5th intercostal space, left midclavicular line."
"Which statement is accurate about assessing the spleen? - CORRECT ANSWER It must be
enlarged at least three times normal size for it to be palpable." "During an external examination of the eyes, the nurse gently palpates the eyes while the client's eyelids are closed. The eyes are both very firm and resist movement back into the orbit. How
should the nurse document this finding? - CORRECT ANSWER Abnormal"
"Which tool should the nurse use when assessing the neurological status of a client with
traumatic brain injury? - CORRECT ANSWER Glasgow Coma Scale"
"The nurse is assessing a client with liver disease who is jaundice and exhibits scleral edema. During the health assessment, the nurse should implement which technique to determine
evidence of hepatomegaly? - CORRECT ANSWER Use a bouncing motion to tap the middle
finger placed within boundaries of the liver." "What is the best nursing response to an older client who has not mentioned incontinence during
a genitourinary assessment? - CORRECT ANSWER Ask the client specifically about any
leakage of urine." "The nurse is assessing a client for a hip flexion contracture. Which finding indicates a negative
Thomas test when the client's right knee is brought toward the chest? - CORRECT ANSWER
The left leg remains on the table" "The nurse is assessing a client who has a history of aortic regurgitation. Where should the nurse place the stethoscope diaphragm to listen for this condition? A) 2nd intercostal space along the right sternal border. B) 2nd intercostal space along the left sternal border. C) 3rd intercostal space on the right midclavicular line.
D) 5th intercostal space on the left midclavicular line. - CORRECT ANSWER a"
"The nurse is assessing a client who has experienced a sudden onset of hearing loss in the right ear. Which finding should alert the nurse to a potentially serious medical condition that requires
further evaluation? - CORRECT ANSWER There is no sign of an associated infection"
"Which information should the nurse obtain to identify the client's self-perception of health
status? - CORRECT ANSWER Health History"
"During the initial assessment, the nurse notes that a client has blurred vision with cloudy lenses. Which condition should the nurse document? Cataracts Pink eye Corneal abrasion
Glaucoma - CORRECT ANSWER Cataracts"
"Which condition is indicated by a fluorescent, yellow-green color when the nurse uses a Wood's
lamp toexamine a client's skin lesions? - CORRECT ANSWER Fungal infection"
"A client with dark skin is reporting a painful and itching area on the lower left leg. What should
the nurse look for when assessing this client's skin for inflammation? - CORRECT ANSWER
Change in consistency" "A client reports pain when taking a deep breath. Which lung auscultation sound should the
nurse anticipate hearing? - CORRECT ANSWER Pleural friction rub"
client's right kidney? - CORRECT ANSWER A round smooth mass that slides between the
fingers." "A client reports lower abdominal pain and a feeling of pressure in the bladder. Which
assessment finding indicates acute urinary retention? - CORRECT ANSWER Dull sound
percussed over bladder" "The nurse examines the skin of an older adult client. Which skin variation is considered a
normal finding for a client in this age group? - CORRECT ANSWER Lentigines"
"During a client's routine well-woman physical exam, the nurse examines the breasts. Which
assessment technique should the nurse implement to evaluate for any abnormal lumps? -
CORRECT ANSWER With both arms at client's side, lift one arm and palpate the axilla."
"The nurse is completing a physical exam on an adult client. Which thyroid finding is considered
normal? - CORRECT ANSWER Gland is not palpable"
"How should the nurse assess for lower extremity edema in a client who has been diagnosed with
heart failure? - CORRECT ANSWER Measure bilateral ankle circumference with a non-
stretchable tape measure." "A client has come to the clinic for a routine health assessment. What is the best assessment
question for the nurse to ask a client after observing tophi on the client's ear cartilage? -
CORRECT ANSWER Have you had sudden and severe pain in your toes or feet?"
"During the interview portio of the health assessment, a nurse notes the person's posture,
physical appearance, and ability to converse. How should the nurse document these findings? -
CORRECT ANSWER Objective"
"The nurse is assessing a client who reports having shoulder pain. Which sign is the best
indicator of a rotator cuff tear? - CORRECT ANSWER Inability to slowly lower the arm when
abducted." "During cardiac auscultation, the nurse hears a split in the second heart sound when listening at the second left intercostal space of a male client. To assess this sound more fully, what action
should the nurse implement? - CORRECT ANSWER Listen to the sound while observing the
client's respirations." "An older client has just returned to the room following a surgical procedure. Which pain scale
should the nurse use when assessing the client's pain level? - CORRECT ANSWER Verbal
descriptor scale"
"The nurse observes peristaltic movement in the left lower quadrant of a client's abdomen.
Which further assessment of the area should the nurse perform? - CORRECT ANSWER
Observe the direction of movement" "The nurse is assessing a client's middle lung lobe. What is the best location for the nurse to place
a stethoscope diaphragm to hear normal lung sounds in this lobe? - CORRECT ANSWER 4th
intercostal space, right midclavicular line" "While performing a head-to-toe assessment, the nurse assesses the client's pupillary accommodation. During the second portion of the test, the nurse notes that the client's pupils constrict and there is convergence of the axes of the eyes. What action should the nurse
implement next? - CORRECT ANSWER Document a normal finding"
"The nurse is performing a head-to-toe assessment on a client. The nurse is assessing the client's pupillary light reflex by first darkening the room and asking the person to gaze into the distance. Then, the nurse advances a light toward one eye from the client's side. What would the nurse expect to see at this time? a. A consensual response in the opposite eye. b. No change in the eye on the opposite side of the face. c. Dilation of the eye on the opposite side of the face.
d. Dilation of the eye on the same side of the face. - CORRECT ANSWER A. A consensual
response in the opposite eye" "A client reports a recent onset of nausea and vomiting. What subjective information is important
for the nurse to ascertain? - CORRECT ANSWER Ask wether client has traveled to a foreign
country recently" "Which term should the nurse use to document the condition of a client who reports waking up
frequently during the night to urinate? - CORRECT ANSWER Nocturia"
"The nurse is assessing for the presence of a hernia. Which action should the nurse ask the client to perform while lying supine? a. Bring the knees toward the chest. b. Place the chin onto the chest. c. Roll from one side to the other.
d. Use abdominal muscles to sit up. - CORRECT ANSWER D"
"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? - CORRECT ANSWER
Note the character and frequency of bowel sounds"
b. Percussion. c. Deep palpation.
d. Inspection. - CORRECT ANSWER B"
"After completing the initial general assessment, the nurse is now completing a focused abdominal assessment of a client who was admitted for abdominal pain. Which assessment is
most important for the nurse to implement? - CORRECT ANSWER Palpate the abdomen after
auscultating for bowel sounds" "A nurse is providing discharge teaching to a client following a heart transplant. Which of the following information should the nurse include in
the teaching? - CORRECT ANSWER Shortness of breath might be an indication of transplant
rejection" "A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and is receiving 3 % sodium chloride via continuous IV. Which of the following laboratory
finding should the nurse identify as an indication that the SIADH is resolving? - CORRECT
ANSWER Urine specific gravity 1.020"
"Picture of mannequin with white dry lips. What does this indicate - CORRECT ANSWER
Dehydration"
"What is the first thing a nurse should do when assessing carotid artery? - CORRECT
ANSWER Check for redness or swelling"
"How to ausculate the carotid artery? - CORRECT ANSWER 1. angle of jaw
- mid-cervical area
- the base of neck"
"Picture of the nurse with stethoscope on posterior lower left lung. What is she listening to? -
CORRECT ANSWER Checking the lungs for vesicular sounds"
"When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low-pitched, soft breath sounds are heard with inspiration being longer than expiration.
This indicates - CORRECT ANSWER Vesicular lung sounds that are normal in that location"
"Picture of clubbing nails - CORRECT ANSWER 180+"
"What do you do if patient has clubbing nails - CORRECT ANSWER Check oxygen"
"Where to look for cyanosis on darker skinned clients? - CORRECT ANSWER -Oral mucosa
-Nail Bed -Conjunctiva"
"Nurse sees old person with blue hands. This is a sign of - CORRECT ANSWER Cyanosis"
"Cigarette smoking two packs a day for twenty years. What is their smoking age - CORRECT
ANSWER 40"
"Elderly client is taking several medications. What should the nurse do if they are concerned? -
CORRECT ANSWER Have client bring in all medications and supplements they are taking"
"What do you see abnormally in the mouth? - CORRECT ANSWER White curd lesion"
"Elderly patient complains of difficulty hearing especially in a group. What should you ask the
patient - CORRECT ANSWER Have you been tested for hearing aids?"
"If someone has pitting edema, where should you check their pulse? - CORRECT ANSWER
Carotid artery"
"If patient is obese, where do you take their pulse? - CORRECT ANSWER Auscultate carotid
Check for bruits using bell of stethoscope S1 is best place to palpate in obese patients"
"Patient comes in with a fever... - CORRECT ANSWER Answer is something with tonsils"
"14 year old with back pain - CORRECT ANSWER What were you doing when it first
occurred?"
"Elderly patient comes in with longitudinal lines on their nails - CORRECT ANSWER
Normal"
"Native American patient with hypertension - CORRECT ANSWER Something with herbal
medicine"
"Which pattern on the heart do you place the stethoscope - CORRECT ANSWER Z"
"Which device is used to test for hearing - CORRECT ANSWER Turning fork"
"Patient comes into clinic and has a hard time responding to nurse. Son talks in loud volume -
CORRECT ANSWER Nurse should step in front so client can see"
