Health Assessment HESI

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Sample questions from Health Assessment HESI

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.A 72-year-old client in the emergency department reports sudden shortness of breath. The client is restless, has crackles throughout both lungs, and is coughing pink, frothy sputum. Vital signs are BP 184/102 mm Hg, HR 124/min, RR 32/min, and SpO2 82% on room air. Which action should the nurse take first?

   • A.Place the client upright and initiate oxygen according to emergency protocol.
   • B.Obtain a detailed history of recent sodium and fluid intake.
   • C.Assess the lower extremities for the extent of pitting edema.
   • D.Obtain a standing weight using the emergency department scale.

   Rationale: Severe hypoxemia with pink, frothy sputum indicates an immediate breathing threat, so positioning and oxygen take priority while emergency assistance is activated. A dietary history and peripheral edema assessment may help determine the cause but must not delay stabilization. A standing weight is unsafe during severe respiratory distress. The exam takeaway is to address oxygenation before completing a comprehensive assessment.

2. 2.A 68-year-old client arrives at an urgent care clinic reporting chest pressure and lightheadedness. The radial pulse feels irregular, BP is 98/62 mm Hg, and RR is 22/min. Which assessment technique best determines the client's ventricular heart rate?

   • A.Count the radial pulse for 15 seconds and multiply by four.
   • B.Auscultate the apical pulse for a full 60 seconds.
   • C.Palpate both carotid arteries simultaneously for 30 seconds.
   • D.Count the pulse oximeter waveform peaks for 15 seconds.

   Rationale: An apical pulse counted for a full minute best assesses ventricular rate when the peripheral pulse is irregular. Short radial counts and pulse oximeter readings can underestimate the rate when some contractions do not produce adequate peripheral perfusion. Simultaneous carotid palpation can compromise cerebral blood flow and is unsafe. The exam takeaway is to use a full-minute apical assessment for an irregular pulse while promptly escalating symptomatic findings.

3. 3.A 54-year-old client in an outpatient clinic reports dizziness when standing after starting a diuretic. After 5 minutes supine, BP is 132/78 mm Hg and HR is 76/min. After standing for 2 minutes, BP is 108/66 mm Hg and HR is 96/min, and the client becomes dizzy. What should the nurse do next?

   • A.Ask the client to remain standing until a 5-minute reading is obtained.
   • B.Document a normal response to position change and continue the examination.
   • C.Assist the client to sit or lie down and report the symptomatic orthostatic change.
   • D.Have the client walk in the hallway to evaluate exercise tolerance.

   Rationale: The systolic decrease of 24 mm Hg and diastolic decrease of 12 mm Hg with dizziness support orthostatic hypotension and require immediate fall prevention. Continuing to stand or walking increases the risk of syncope and injury. These findings are not a normal positional response. The exam takeaway is to interpret orthostatic measurements together with symptoms and protect the client first.

4. 4.A 61-year-old client with darkly pigmented skin is assessed in a medical clinic for fatigue and reduced activity tolerance. HR is 102/min and hemoglobin is 8.1 g/dL. Which site is most useful for assessing pallor?

   • A.The outer surfaces of the forearms
   • B.The skin over the anterior shins
   • C.The upper back between the scapulae
   • D.The lower palpebral conjunctivae

   Answer and rationale are in the full material.

5. 5.A 70-year-old client is evaluated in the emergency department for sudden right arm weakness and slurred speech that began 40 minutes ago. BP is 176/94 mm Hg, SpO2 is 96%, and bedside glucose is 48 mg/dL. Which action is the priority while the stroke evaluation continues?

   • A.Treat the hypoglycemia according to protocol and reassess neurologic findings.
   • B.Give oral juice before assessing swallowing ability.
   • C.Delay treatment until the head CT result is available.
   • D.Lower the blood pressure to the client's usual baseline immediately.

   Answer and rationale are in the full material.