NIGHTINGALE BSN 246 HESI HEALTH

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NIGHTINGALE BSN 246 HESI HEALTH

ASSESSMENT EXAM 2025 VERSION 3 WITH 500

REAL EXAM QUESTIONS AND CORRECT

ANSWERS GRADED A+/ HESI HEALTH

ASSESSMENT EXAM/ BSN 246 EXAM 2024/2025

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.

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.)

• Diminished hair on legs.
• Bruising on extremities.
• Skin cool to touch.
• Capillary refill less than 3 seconds.
• Darkened skin on extremities.

A, C Which action should the registered nurse (RN) implement to complete an assessment for a client while using an interpreter?

• Ask closed-ended questions with the assistance of the interpreter.
• Maintain eye contact with the client while listening to the translation.
• Instruct interpreter to answer questions from interpreter's point of view.
• Protect the client's privacy by asking a limited number of questions.

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pg. 2 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.

A, D, E

Registered nurse (RN) is performing a mini-mental state examination (MMSE) for a client who is being admitted to an assisted living community. Which communication techniques should the RN implement to decrease anxiety in the client? (Select all that apply.)

• Use simple sentences during the examination.
• Move to another question if the client seems confused.
• Reduce environmental detractors during the examination.
• Allow family to answer for the client to decrease frustration.
• Ask questions one at a time to decrease confusion.

A, C, E

A Muslim male client refuses to let the female registered nurse (RN) listen to his breath sounds during the examination. How should the RN respond?

• Explain how the nursing skill will be performed before proceeding.
• Examine client with an additional healthcare provider for support.
• Request a male nurse or healthcare provider to perform the exam.
• Avoid any skills that involve touching the client during the exam.

C 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. 2 / 4

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• Delay administration of ipratropium until next maintenance medication is

scheduled.A 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).

• Type I diabetes mellitus (DM).
• Closed angle glaucoma.
• Chronic hypertension.
• Rheumatoid arthritis.
• Crohn's disease.

B, C 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.

B The registered nurse (RN) notifies the spouse of a client who was admitted to hospice with shallow respirations, of a change in the client's condition. Over the past hour, the client's respiratory pattern has changed to a Cheyne Stokes pattern.After receiving this information, the client's spouse begins vacuuming around the bed. Which stage of grief is the spouse displaying during the visit?

• Acceptance.
• Denial.
• Bargaining.
• Depression.

B 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 3 / 4

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• 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.

A, C, E

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).

• Hematemesis.
• Gastric pain on an empty stomach.
• Colic-like pain with fatty food ingestion.
• intolerance of spicy foods.
• Diarrhea and stearrhea.

A, B, D

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.

A 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.
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