HESI V2 Health Assessment Nightingale

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Sample questions from HESI V2 Health Assessment Nightingale

This material has 60 questions with answers and rationales. Here are the first 5.

1. 1.A 68-year-old client arrives at the emergency department with sudden dyspnea. The client is restless, speaks in two-word phrases, and has a respiratory rate of 32/min and oxygen saturation of 84% on room air. Which assessment finding requires the most immediate intervention?

   • A.Bilateral ankle edema
   • B.Inability to speak full sentences
   • C.A productive cough for 3 days
   • D.An oral temperature of 100.4 F

   Rationale: Inability to speak full sentences indicates severe respiratory distress and requires immediate support of oxygenation and ventilation. Ankle edema suggests fluid retention, while cough and low-grade fever may help identify the cause but are not the immediate threat. Prioritize current airway and breathing impairment over findings that explain its origin.

2. 2.A 54-year-old client at a primary care clinic has a blood pressure of 168/94 mm Hg measured immediately after walking from the parking lot. The cuff bladder is too small for the client's upper arm. What should the nurse do next?

   • A.Repeat the measurement after 5 minutes of rest using an appropriately sized cuff
   • B.Document the reading as the client's baseline blood pressure
   • C.Measure the pressure over the client's sleeve with the same cuff
   • D.Ask the client to hold the arm above the head during the repeat measurement

   Rationale: Rest and an appropriately sized cuff improve measurement accuracy because exertion and an undersized cuff can produce falsely elevated readings. Documenting this value as baseline ignores measurement errors, and measuring over clothing can further distort the result. Holding the arm above heart level can falsely lower the reading; support it at heart level instead.

3. 3.An 82-year-old client on a medical unit becomes newly confused over 2 hours. The client was oriented at admission yesterday and now has a temperature of 101.3 F, heart rate of 108/min, and oxygen saturation of 89% on room air. Which interpretation should guide the nurse's immediate assessment?

   • A.The client is demonstrating expected age-related memory loss
   • B.The client probably has gradually progressive dementia
   • C.The client may have delirium related to an acute physiologic problem
   • D.The client needs cognitive testing before physiologic assessment

   Rationale: An acute change in attention or cognition with fever and hypoxemia suggests delirium and requires prompt assessment of reversible causes. Expected aging does not cause sudden confusion, and dementia usually develops gradually. Formal cognitive testing must not delay assessment and treatment of hypoxemia or infection.

4. 4.A 47-year-old client in an outpatient clinic reports dizziness when standing. After 5 minutes supine, blood pressure is 132/78 mm Hg and heart rate is 76/min; after standing for 1 minute, blood pressure is 106/66 mm Hg and heart rate is 98/min. What is the nurse's best action?

   • A.Ask the client to walk down the hallway to assess endurance
   • B.Reassure the client that the blood pressure remains acceptable
   • C.Repeat the standing measurement in 30 minutes without assistance
   • D.Assist the client to sit or lie down and evaluate contributing factors

   Answer and rationale are in the full material.

5. 5.A 59-year-old client in the emergency department reports a sudden severe headache that reached maximum intensity within seconds while lifting a box. Blood pressure is 184/102 mm Hg, and the client reports neck stiffness. Which action has priority?

   • A.Arrange a routine vision screening
   • B.Immediately escalate care for a possible intracranial hemorrhage
   • C.Complete a detailed dietary headache-trigger history
   • D.Place the client in a quiet room and reassess in 1 hour

   Answer and rationale are in the full material.