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BSN 246 HESI HEALTH ASSESSMENT EXAM
QUESTIONS AND VERIFIED ANSWERS WITH SUCCESS GUARANTEED
“The nurse reviews the health record of a client with melasma. The nurse would anticipate that
this client will exhibit: - CORRECT ANSWER Blotchy brown macules across the cheeks and
forehead" "A client is admitted to the hospital with cellulitis of the lower leg. The nurse would anticipate
which of the following therapies to be prescribed? - CORRECT ANSWER Warm compresses to
the affected area" "The nurse has instructed the client in the correct technique for breast self-examination (BSE). For a portion of the examination, the client will lie down. If the client were to examine the right
breast, the nurse would tell the client to place a pillow: - CORRECT ANSWER Under the right
shoulder" "The nurse would identify that which of the following foods should be increased in the diet to
help decrease the risk of cancer development? - CORRECT ANSWER Broccoli"
"The nurse would include which of the following in a list of the most helpful foods for the vegan
client wishing to increase foods high in vitamin A? - CORRECT ANSWER carrots"
"According to the American Cancer Society, fecal occult blood testing should be done annually
after the age of _____ years. - CORRECT ANSWER 50"
"The nurse is caring for a client with a dysfunctional thyroid gland and is concerned that the client will exhibit signs of thyroid storm. Which of the following is an early indicator of this
complication? - CORRECT ANSWER Hyperreflexia"
"The client is undergoing an oral glucose tolerance test. The nurse interprets that the client's results are not compatible with diabetes mellitus if the glucose level is lower than which of the
following cutoff values after 120 minutes (2 hours)? - CORRECT ANSWER 140 mg/dL"
"A client who visits the physician's office for a routine physical reports new onset of intolerance to cold. Knowing that this is a frequent complaint associated with hypothyroidism, the nurse
continues to assess for which of the following? - CORRECT ANSWER Complaints of weakness
and lethargy"
"The nurse is caring for a client diagnosed with suspected acute pancreatitis. When reviewing the client's laboratory results, the nurse determines that which of these findings will support the
diagnosis? - CORRECT ANSWER Elevated serum levels"
"A nurse is caring for a client postoperatively following creation of a colostomy. Which of the
following nursing diagnoses should the nurse include in the plan of care? - CORRECT
ANSWER Disturbed body image"
"The client is experiencing blockage of the common bile duct. Which of the following food
selections made by the client indicates the need to plan for further diet teaching? - CORRECT
ANSWER Whole milk"
"The nurse is preparing to take an apical pulse on an assigned client. The nurse places the
diaphragm of the stethoscope at which cardiac site? - CORRECT ANSWER Mitral Valve"
"The nurse reading the operative record of a client who had cardiac surgery notes that the client's cardiac output immediately after surgery was 3.2 L/min. Evaluation of the cardiac output results
leads the nurse to make which of the following conclusions? - CORRECT ANSWER The
cardiac output is below the normal range" "A nurse is caring for a client diagnosed with Ménière's disease. The nurse plans care,
understanding that this disorder is characterized by: - CORRECT ANSWER Dizziness"
"The client has a cerebellar lesion. The nurse would plan to obtain which of the following for use
by this client? - CORRECT ANSWER Walker"
"The client has sustained damage to Wernicke's area in the temporal lobe from a brain attack
(stroke). Which of the following should the nurse anticipate when caring for this client? -
CORRECT ANSWER The client will have difficulty understanding language."
"The nurse is preparing to administer a prescribed antibiotic to a client with bacterial meningitis. The nurse understands that the selection of an antibiotic to treat meningitis is based on which of
the following? - CORRECT ANSWER It is able to cross the blood-brain barrier."
"The client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into the 50 to 56 beats/min range. The client is also complaining of nausea. The nurse
interprets that these symptoms are because of stimulation of which cranial nerve (CN)? -
CORRECT ANSWER Vagus CN: X"
promote client safety? Select all that apply. - CORRECT ANSWER -Provide the client with a
soft toothbrush. -Instruct the client to use an electric razor. -Monitor all secretions for frank or occult blood." "The nurse is doing volunteer work in a homeless shelter. The nurse monitors the individuals in the shelter for which of the following initial symptoms of tuberculosis (TB)? Select all that apply.
CORRECT ANSWER Fatigue
Lethargy Low-grade fever Morning cough" "The registered nurse (RN) is caring for a client who has a closed head injury from a motor vehicle collision. Which finding should the RN assess the client for the risk of diabetes insipidus (DI)? High fever. Low blood pressure. Muscle rigidity.
Polydipsia. - CORRECT ANSWER Polydipsia.
Rationale A characteristic finding of DI is excretion of large quantities of urine (5 to 20L/day), and most clients compensate for fluid loss by drinking large amounts of water (polydipsia). DI can occur when there has been damage or injury to the pituitary gland or hypothalamus as a result of head trauma, tumor or an illness such as meningitis. This damage interrupts the ADH production, storage and release causing the excessive urination and thirst." "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. Rationale To ensure compliance the client's native language, education level, lifestyle, and financial resources should be considered when preparing the client's discharge instructions about the continuation of treatment for TB." "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.
Rationale Stiffness in joints is an early sign of contractures and muscle atrophy related to inactivity and immobility." "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
brusing. Rationale Cold applications produce a topical anesthetic effect to reduce pain as well as constricts blood vessels to minimize 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.
Night sweats. - CORRECT ANSWER Phlegm production and wheezing.
Rationale A chronic seasonal cough related to bronchitis is likely accompanied withphlegm production and wheezing. Although smoking can contribute to a chronic cough, the typical seasonal cough is an inflammatory reaction to seasonal changes." "The registered nurse (RN) is caring for a client with peptic ulcer disease (PUD). What assessment should the RN identify and document that is consistent with PUD? (Select all that apply). Select all that apply Hematemesis. Gastric pain on an empty stomach. Colic-like pain with fatty food ingestion. Intolerance of spicy foods.
Diarrhea and stearrhea. - CORRECT ANSWER Hematemesis.
Gastric pain on an empty stomach. Intolerance of spicy foods. Rationale Manifestations of PUD include hematemesis, gastric pain, and spicy food intolerance." "A female client calls the clinic and talks with the registered nurse (RN) to inquire about a possible reaction after taking amoxicillin for 5 days. She reports having vaginal discomfort, itching, and a white discharge. The RN should discuss which action with the client? Discontinue the antibiotic because original symptoms have subsided. Continue taking medication until finished until the symptoms subside. Consult with healthcare provider about another treatment for this effect.
Use an over-the-counter (OTC) vaginal wash to flush out the secretions. - CORRECT ANSWER
Consult with healthcare provider about another treatment for this effect. Rationale A superinfection with normal flora yeast may occur during antibiotic therapy. If suspected, the new onset of findings should be reported to the healthcare provider for another prescribed treatment to treat the superinfection."
"An infant with heart failure receives a prescription, digoxin 35 mcg PO. The registered nurse (RN) calcuates the desired dose for administration using the available concentration of digoxin labeled, 0.05 mg/mL. How many millilitersshould the registered nurse (RN) prepare for administration?(Enter the numerical value only. If rounding is required round to the nearest
tenth.) - CORRECT ANSWER 0.
Rationale Desired dose, 35 mcg converts to 0.035 mg because the equivalent is 1 mg = 1,000 mcg Using the formula, D/H x A = 0.035 mg / 0.05 mg x 1 mL = 0.7 mL the ratio proportion method of: 35mcg/X ml :: 1000mcg/1mL = 0.035mg; 0.035mg/XmL :: 0.05mg/mL =0.035mg/0.7mL" "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. Rationale RLQ rebound abdominal tenderness may be related to acute appendicitis and should be reported to the healthcare provider." "While reviewing the client's electronic medical record (EMR), the registered nurse (RN) assesses a client who is at risk for a possible interaction with an over-the-counter (OTC) decongestant. Which client health history should the RN report to the healthcare provider concerning the OTC medication? (Select all that apply). Select all that apply Type I diabetes mellitus (DM). Closed angle glaucoma. Chronic hypertension. Rheumatoid arthritis.
Crohn's disease. - CORRECT ANSWER Closed angle glaucoma.
Chronic hypertension. Rationale
A chest x-ray should be performed immediately after the removal of a chest tube to ensure lung expansion has been maintained after its removal." "The registered nurse (RN) is caring for a client who developed oliguria and was diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding indicates to the RN that the client is stabilizing? Urine output of 40 mL/hour. Apical pulse 100 and blood pressure 76/42. Urine specific gravity 1.001.
Tented skin on dorsal surface of hands. - CORRECT ANSWER Urine output of 40 mL/hour.
Rationale A decrease in urinary output is a sign of dehydration. When the urine output returns to a normal range, 40 mL/hour, the client's kidneys are perfusing adequately and indicates the client's status is stablizing." "The registered nurse (RN) is caring for a client with acute pancreatitis and assesses the admission laboratory results. What laboratory value should the RN anticipate being elevated with this diagnosis? Triglycerides. Amylase. Creatinine.
Uric acid. - CORRECT ANSWER Amylase.
Rationale An elevated amylase level is associated with acute pancreatitis." "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? African American women. Caucasian women. Asian women.
Hispanic women. - CORRECT ANSWER African American women.
Rationale
Sarcoidosis, an autoimmune inflammatory disease affecting multiple organs and has shown familial tendency due to multiple genes that together increase the susceptibility of developing the disease. In research studies it occurs more commonly in African American women (10-80 out of 100,000); compare to Caucasian women of the United States (8 out of 100,000)." "A client who is uses ipratropium reports having nausea, blurred vision, headaches, and insomnia after using the inhaler. Which action should the registered nurse (RN) implement first? A client who is uses ipratropium reports having nausea, blurred vision, headaches, and insomnia after using the inhaler. Which action should the registered nurse (RN) implement first? Withhold medication and report symptoms and vital signs to healthcare provider. Give PRN medication for nausea and vomiting and evaluate client in 30 minutes. Reassure client that the ipratropium given will alleviate the symptoms. Delay administration of ipratropium until next maintenance medication is scheduled. Give PRN medication for nausea and vomiting and evaluate client in 30 minutes. Reassure client that the ipratropium given will alleviate the symptoms.
Delay administration of ipratropium until next maintenance medication is scheduled. -
CORRECT ANSWER Withhold medication and report symptoms and vital signs to healthcare
provider. Rationale Headache, nausea, blurred vision and insomnia are symptoms of excessive use of ipratropium, so withholding the medication until the healthcare provider is notified should be initiated to maintain client safety." "The registered nurse (RN) is assessing a client who was discharged home after management of chronic hypertension. Which equipment should the RN instruct the client to use at home? Exercise bicycle. Sphygmomanometer. Blood glucose monitor.
Weekly medication box. - CORRECT ANSWER Sphygmomanometer.
Rationale Self-awareness is the best way for a client to manage chronic hypertension, so the client should obtain a sphygmomanometer and learn how to monitor blood pressure daily and maintain a record." "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
"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.
Rationale The consumption of any type of tyramine containing foods such as aged cheeses, fermented fruits and vegetables, smoked or cured meats, dark wines and other alcoholic products should be avoided when a client is prescribed a MAOIs due to the a food-drug interaction causing a hypertensive crisis which can lead to a hemorrhagic stroke." "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. Rationale A client with hearing loss can develop the ability to read "lips," so facing the client during conversation allows visualization of the lips and directs the sound towards the client. Inspection of the hearing aide device's functionality is a vital step in communication. Hearing aides magnify all surrounding noise, so it is imperative to reduce outside environmental noise during the interview process. Speaking clearly with enunciation and in a regular tone is easier for a client to understand than increasing the volume of speech. If a client shows signs of confusion, rephrasing
the question, instead of repeating, should be done to decrease client anxiety and facilitate understanding." "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 oximetry values. Rationale Beta 2 receptor agonist agents should provide immediate return of airflow and resolve wheezing and improve oxygenation." "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. Auscultate over the epigastrium while injecting air into the NGT. Disconnect and place the end of NGT in water to see if bubbles appear.
Listen for hyperactive bowel sounds in all four quadrants of abdomen. - CORRECT ANSWER
Check pH of aspirated stomach contents obtained from the NGT. Rationale Checking the pH of the aspirate is the best method to validate that the NGT is not displaced and should reveal an acidic pH of 1.5 to 3.5 due to presence of gastric acid." "An older client is admitted to the hospital with severe diarrhea. The registered nurse (RN) is completing an assessment and notes the client has dry mucous membranes and poor skin turgor. Which assessment data should the RN gather to determine if the client has a fluid volume deficit? Lower extremity edema. Orthostatic hypotension.
Protect the client's privacy by asking a limited number of questions. - CORRECT ANSWER
Maintain eye contact with the client while listening to the translation. Rationale When completing an assessment, the RN should maintain eye contact with the client to gather additional information from the client's nonverbal cues." "The registered nurse (RN) is caring for a client with aplastic anemia who is hospitalized for weight loss and generalized weakness. Laboratory values show a white blood count (WBC) of 2,500/mm3 and a platelet countof 160,000/mm3. Which intervention is the primary focus in the client's plan of care for the RN to implement? Assist with frequent ambulation. Encourage visitors to visit. Maintain strict protective precautions.
Avoid peripheral injections. - CORRECT ANSWER Maintain strict protective precautions.
Rationale The client should be under strict protective transmission precautions because the WBC values are low and normal WBC levels are 4,000-10,000/mm3, so the client is an increased high risk for infection." "After a liver biopsy is performed at the bedside, the registered nurse (RN) is assigned the care of the client. Which nursing intervention is most important for the RN to implement? Position client on left side with pillow placed under the costal margin. Assist the client with voiding immediately after the procedure. Evaluate vital signs q10 to 20 minutes for 2 hours after procedure.
Ambulate client 3 times in first hour with pillow held at abdomen. - CORRECT ANSWER
Evaluate vital signs q10 to 20 minutes for 2 hours after procedure. Rationale Vital signs should be checked every 10 to 20 minutes to assess for bleeding after biopsy of the liver, which is highly vascular. The client should be positioned on the right sidewith a pillow or sandbag under the costal margin and supporting the biopsy site. The client should be maintained on bedrest for several hours to decrease the risk of bleeding from the biopsy site." "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? Lower back pain.
Headache of 7 on scale 1 to 10. Blood pressure of 140/98.
Dyspnea. - CORRECT ANSWER Dyspnea.
Rationale A client with a large bone fracture is at risk for intramedullary fat leaking into the blood stream and becoming embolic. Dyspnea is an indication of fat embolism to the lungs and should be reported to the healthcare provider immediately." "A client with chest pain, dizziness, and vomiting for the last 2 hours is admitted for evaluation for Acute Coronary Syndrome (ACS). Which cardiac biomarker should the registered nurse (RN) anticipate to be elevated if the client experienced myocardial damage? Creatine Kinase (CK-MB). Serum troponin. Myoglobin.
Ischemia modified albumin. - CORRECT ANSWER Serum troponin.
Rationale Troponin is the most sensitive and specific test for myocardial damage. Troponin elevation is more specific than CK-MB." "The registered nurse (RN) did not note that a prescription dose was recently changed and did not note the updated medication administration record (MAR). After giving the client the original dose, the RN reports the medication error to the nurse manager. What consequences will the RN experience due to this error in medication administration? The incident will be reported to the state's Board of Nursing (BON). A medication error report will be completed and risk management will be notified. The RN will be suspended from medication administration until the error is investigated.
The incident will be documented in the RN's personnel file. - CORRECT ANSWER A
medication error report will be completed and risk management will be notified. Rationale By reviewing quality of care internally, steps of care can be evaluated and staff can be educated where gaps are identified. The medication report and notification of management is the responsibility of the RN who made the mistake, so an internal review of the steps of the occurrence can be completed to determine further risk potentials."
Chronic constipation causes weakening of colon wall which result in out-pouching sacs. -
CORRECT ANSWER Chronic constipation causes weakening of colon wall which result in
out-pouching sacs. Rationale A client who has chronic constipation often strains to pass constipated stool which increases intestinal pressure that weakens the intestinal walls and causes out-pouching sacs, called diverticula which commonly occur in the sigmoid." "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? Recall of information. Orientation to surroundings. Attention to details.
Ability to follow complex commands. - CORRECT ANSWER Attention to details.
Rationale When conducting the MMSE and having the client count backwards by 7s; this evaluates their ability to do simple calculations and is specific to the client's attention to detail and staying focus and not getting distracted by external stimuli." "Twenty four hours after a client returns from surgical gastric bypass, the registered nurse (RN) observes large amounts of blood in the nasogastric tube (NGT) cannister. Which assessment finding should the RN report as early signs of hypovolemic shock? Faint pedal pulses. Decrease in blood pressure. Lethargy.
Slow breathing. - CORRECT ANSWER Lethargy.
Rationale One of the early signs of hypovolemic shock is changes in the client's level of consciousness due to the decrease perfusion to the brain which can manifests as lethargy or confusion." "The registered nurse (RN) is assessing common complications related to a client's recent diagnosis, systemic lupus erythematosus (SLE). Which symptom should the RN instruct the client to report immediately? Fever related to infection.
Weight loss and anorexia. Depressed mood.
Break in tissue integrity. - CORRECT ANSWER Fever related to infection.
Rationale Secondary infections are a major concern with SLE clients due to the use of corticosteroids and chemotherapeutic agents, which suppresses the immune system, so reporting fever and infections should be reported immediately." "The registered nurse (RN) is caring for an Asian client who refuses to make eye contact during conversations. How should the RN assess this client's response? The client cannot understand the nurse. The client is uncomfortable with the nurse. The client is treating the nurse with respect.
The client is purposefully disrespecting the nurse. - CORRECT ANSWER The client is treating
the nurse with respect. Rationale In some Asian cultures, it is not appropriate to look a person of authority in the eye, so the client is being respectful by looking down while speaking with the nurse." "A male client is admitted after falling from his bed. The healthcare provider (HCP) tells the family that he has an incomplete fracture of the humerus. The family ask the RN what this means. Which type of fracture should the RN explain from these findings? Straignt fracture line that is also a simple, closed fracture. Nondisplaced fracture line that wraps around the bone. A complete fracture that also punctures the skin.
A fracture that bends or splinters part of the bone. - CORRECT ANSWER A fracture that
bends or splinters part of the bone. Rationale An incomplete fracture occurs when part of the bone is splintered (broken) and it has not gone completely through the thickness of the bone." "While caring for a client who has esophageal varices, which nursing intervention is most important for the registered nurse (RN) to implement? Monitor infusing IV fluids and any replacement blood products.
