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University of Pennsylvania Complete 2025
Physical Assessment HESI Practice Exam for
Aspiring Nurses – Study Smarter and Score Higher
The nurse can best determine the effect of crying on a patient's apical pulse by doing what? A. Measuring the patient's apical pulse before and after crying B. Assessing the patient's apical pulse 30 minutes after crying C. Comparing the patient's post-crying apical pulse rate with her baseline or previous rate D. Measuring the patient's pulse deficit after crying - - correct ans- - C. Comparing the patient's post-crying apical pulse rate with her baseline or previous rate The comparison of apical pulse rates at these times is the best means of evaluating the effect of crying on the patient's apical pulse rate. These values would be available data to compare. It is unlikely that the nurse will have the opportunity to measure the patient's apical pulse before and after crying. The time interval of 30 minutes is too long to effectively assess the effect of the crying on the apical pulse. Pulse deficit indicates alterations in cardiac output, not the effect of the emotional reaction. How often should normal bowel sounds be heard in each quadrant of the abdomen? A. 5-35 times per minute B. Less than 5 times per minute C. 15-20 times per minute D. 20-40 times per minute - - correct ans- - A. 5-35 times per minute
Normal bowel sounds should be heard 5-35 times per minute. Bowel sounds reflect peristalsis and should be heard irregularly During a well-baby check for several 4-month-old infants, a nurse recognizes that which infant needs further assessment of an abnormal finding? a. The infant who is unable to sit independently b. The infant whose head circumference and chest circumference are equal c. The infant whose weight has doubled since birth d. The infant whose length falls in the 90th percentile on growth charts - - correct ans- - ANS: B Feedback A This is not an expected motor skill for a 4-month-old; it is expected at 6 months of age. B At four months of age, the head circumference should be larger than the chest circumference. C This is a normal finding; infants generally double their birth weight by age 4 to 5 months. D This is not an abnormal finding, especially if weight is normal; the height of the parents should also be considered. What is the correct order for abdominal assessment? A. Inspection, palpation, auscultation, percussion B. Inspection, auscultation, percussion, palpation C. Auscultation, inspection, palpation, percussion D. Palpation, inspection, auscultation, percussion - - correct ans- - B. Inspection, auscultation, percussion, palpation
D This describes an incorrect technique. Which of the following is an important part of performing an abdominal assessment? A. Completing the assessment as quickly as possible B. Stopping the assessment if the patient has any tenderness C. Explaining each step of the assessment to the patient D. Having the patient breathe normally at all times - - correct ans- - C. Explaining each step of the assessment to the patient Explaining each step of the assessment demonstrates respect for the patient and allows the patient to be informed of the assessment process. Abdominal assessment should be performed in a thorough manner, not as quickly as possible. Complaints of tenderness from the patient should be noted, and the complete abdominal assessment should be continued. For most parts of the assessment, the patient will breathe normally. There are instances when the patient will need to take a deep breath, such as when assessing the spleen and gastric air bubble Based on Mr. Kapur's report of increasingly frequent periods of dyspnea, dizziness, and minor chest discomfort, what assessment should the nurse perform next? Ask the client to stand and then recheck the blood pressure. Assessment of the client for orthostatic hypotension is important, but another assessment takes priority. Place the client in a supine position and observe for orthopnea. Assessment for orthopnea is important, but another assessment takes priority. Measure the apical and radial pulse rates at the same time.
Assessment of the client for an apical-radial deficit is important, but another assessment should be completed first. Determine if the client is currently experiencing any angina. Because the client has a history of chest discomfort, the nurse should first determine if the client is currently experiencing angina. Angina should be treated immediately to reduce the risk for myocardial damage. - - correct ans- - Determine if the client is currently experiencing any angina. Because the client has a history of chest discomfort, the nurse should first determine if the client is currently experiencing angina. Angina should be treated immediately to reduce the risk for myocardial damage. Mr. Kapur denies any current symptoms, including angina. After palpating an irregular pulse rhythm at the left radial pulse site, what action should the nurse take to confirm the client's heart rate? Palpate both radial pulses simultaneously. This is not the best method to confirm the heart rate of a client with an irregular cardiac rhythm. Auscultate the apical pulse for 1 minute. Auscultation of the apical pulse is the most accurate method to determine heart rate and rhythm because the nurse is listening directly over the heart, rather than depending on the transmission of the pulse to a distal site, such as the radial pulse site. Compare the ulnar pulse to the radial pulse. The ulnar pulse is often difficult to palpate and is not the best site to use to assess cardiac rate and rhythm. Ask the client if he experiences palpitations.
To obtain information that will help distinguish whether the client's fatigue is cardiac in nature, what question should the RN ask the client? "Why do you feel your fatigue is related to your age?" This question is unlikely to elicit information related to the cause of the fatigue. "Can you describe the quality of your fatigue?" The quality of fatigue is difficult to describe and typically non-specific to the cause of the fatigue. "What do you do when you feel tired?" The client's response to fatigue is unlikely to elicit information related to the cause of the fatigue. "At what time of day do you feel most fatigued?" Fatigue related to stress or depression may be worse in the morning or may be present all day, while fatigue related to decreased cardiac output may worsen in the evening. Tomas tells the RN that he gets progressively more fatigued throughout the day. - - correct ans- - "At what time of day do you feel most fatigued?" Fatigue related to stress or depression may be worse in the morning or may be present all day, while fatigue related to decreased cardiac output may worsen in the evening. Tomas tells the RN that he gets progressively more fatigued throughout the day. Before developing the client's plan of care, what information is most important for the nurse to obtain regarding the client's spirituality? Whether the client participates in formal religious services regularly. Other information is more pertinent to the plan of care. How the client's spiritual beliefs impact his health care expectations.
In planning care, the RN should try to determine how the client's spiritual and cultural beliefs impact the expectations for care in the healthcare setting. What beliefs the client holds regarding the existence of a higher power. Other information is more pertinent to the plan of care. The role played by a spiritual advisor within the client's faith tradition. This information may be important in planning the client's care, but another option offers a broader overview of the impact of the client's spiritual needs. - - correct ans- - How the client's spiritual beliefs impact his health care expectations. In planning care, the RN should try to determine how the client's spiritual and cultural beliefs impact the expectations for care in the healthcare setting. It is most important for the nurse to obtain further information related to which aspects of the client's care? Hygiene practices. There are no commonly held beliefs related to hygiene practices in Hinduism. Sleep patterns. There are no commonly held beliefs related to sleep patterns in Hinduism. Exercise habits. There are no commonly held beliefs related to exercise habits in Hinduism. Dietary needs. While there are few commonly held beliefs in Hinduism, many Hindus are vegetarians, so the nurse should assess the client's dietary needs. Herbs or purgatives used.
Right sternal border, 2nd intercostal space. This is the location of the aortic site. The aortic and pulmonic sites are found at the base of the heart. Right sternal border, 4th intercostal space. This is not the location of the base of the heart. Left sternal border, 5th intercostal space. This is not the location of the base of the heart. Left midclavicular line, 5th intercostal space. This is not the location of the base of the heart. - - correct ans- - Right sternal border, 2nd intercostal space. This is the location of the aortic site. The aortic and pulmonic sites are found at the base of the heart. The nurse should observe the force of the impulse at what location? Left midclavicular line, 2nd intercostal space. A left ventricular heave is not observed at this site. Left sternal border, 4th intercostal space. A left ventricular heave is not observed at this site. Right sternal border, 2nd intercostal space. A left ventricular heave is not observed at this site. Left midclavicular line, 5th intercostal space.
A left ventricular heave is seen at the apex, located at the left midclavicular line, 5th intercostal space. This forceful thrusting of the ventricle occurs with hypertrophy of the left ventricle. - - correct ans- - Left midclavicular line, 5th intercostal space. A left ventricular heave is seen at the apex, located at the left midclavicular line, 5th intercostal space. This forceful thrusting of the ventricle occurs with hypertrophy of the left ventricle. Before attempting to palpate again, the nurse should give the client what instruction? Lift his left arm above his head. This instruction will not enable the nurse to palpate the apical impulse. Turn onto his right side. This instruction will not enable the nurse to palpate the apical impulse. Externally rotate his right shoulder. This instruction will not enable the nurse to palpate the apical impulse. Roll half-way to his left side. Turning half-way to the left side moves the apex of the heart closer to the chest wall, so it is easier to palpate. - - correct ans- - Roll half-way to his left side. Turning half-way to the left side moves the apex of the heart closer to the chest wall, so it is easier to palpate Which test result can the nurse review to obtain the same information that might be obtained during precordial percussion? Creatine phosphokinase (CPK). This enzyme level becomes elevated following muscle damage and may be used with other serum lab tests to assess for possible myocardial muscle damage. Percussion of the precordium does not provide information related to myocardial damage.
Lifting the stethoscope from one valve area to the next may prevent the nurse from hearing all sounds produced by the valves. Inch the stethoscope across and down in a "Z" pattern. Inching the stethoscope across the chest and using a systematic pattern ensures that all sounds produced by the valves will be heard. - - correct ans- - Inch the stethoscope across and down in a "Z" pattern. Inching the stethoscope across the chest and using a systematic pattern ensures that all sounds produced by the valves will be heard. While continuing to listen at the aortic site, what action should the RN take? Observe the P wave on the telemetry monitor. S1 occurs at the same time as the R wave, the upstroke of the QRS complex. S1 does not coincide with the P wave. Watch the client's inhalation and exhalation. The client's pattern of inhalation and exhalation does not coincide with S1 or S2. Palpate the carotid artery pulse. S1 occurs simultaneously with the carotid artery pulsation. By gently palpating the carotid artery, the nurse can distinguish S1 as the sound that occurs with each pulsation. Check for a pulse deficit. A pulse deficit is assessed by comparing the apical heart rate with the radial pulse and is not useful in distinguishing S1 and S2. - - correct ans- - Palpate the carotid artery pulse. S1 occurs simultaneously with the carotid artery pulsation. By gently palpating the carotid artery, the nurse can distinguish S1 as the sound that occurs with each pulsation.
What action should the nurse take in response to this finding? Document this normal finding on the initial assessment record. A split S2 is a normal finding that can be heard in some people as the result of the slightly asynchronous closing of the aortic and pulmonic valves. A split S2 is heard best during inspiration at the pulmonic site, the left second intercostal space. Confirm the finding on the bedside cardiac telemetry monitor. A split S2 heart sound cannot be observed on a cardiac monitor. Assess for a change in the client's oxygen saturation reading. A change in oxygen saturation would not be expected in relation to this finding. Contact the healthcare provider (HCP) to report the assessment finding. This action is not warranted in response to this finding. - - correct ans- - Document this normal finding on the initial assessment record. A split S2 is a normal finding that can be heard in some people as the result of the slightly asynchronous closing of the aortic and pulmonic valves. A split S2 is heard best during inspiration at the pulmonic site, the left second intercostal space. In listening at this site, what should the nurse attempt to distinguish first? S1 and S2 heart sounds. The nurse should begin by listening for the normal heart sounds, S1 and S2, before attempting to distinguish abnormal heart sounds, such as S3 and S4 or heart murmurs. Diastolic heart murmur. The nurse should listen for other sounds before listening for heart murmurs.
What action should the nurse take next? Document the findings and report the murmur to the charge nurse. Another action should be taken before documenting or reporting the findings. Repeat auscultation across the chest using the bell of the stethoscope. After completing assessment with the diaphragm of the stethoscope, the nurse should repeat the sequence using the bell of the stethoscope. The bell of the stethoscope is used to listen for relatively lower pitched sounds than the diaphragm. Continue assessment of heart sounds across the client's posterior thorax. Heart sounds are not assessed across the posterior thorax. Plan to repeat the assessment in 1 hour, after the client rests. There is no indication of a need to stop the assessment to allow the client to rest. - - correct ans- - Repeat auscultation across the chest using the bell of the stethoscope. After completing assessment with the diaphragm of the stethoscope, the nurse should repeat the sequence using the bell of the stethoscope. The bell of the stethoscope is used to listen for relatively lower pitched sounds than the diaphragm. How should the nurse identify this sound? Diastolic murmur. A diastolic murmur coincides with the S2 heart sound. Systolic murmur. Murmurs are often heard as a swooshing sound. Systolic murmurs coincide with the S heart sound. S4 heart sound.
The S4 heart sound is not heard at the same time as S1. S3 heart sound. The S3 heart sound is not heard at the same time as S1. - - correct ans- - Systolic murmur. Murmurs are often heard as a swooshing sound. Systolic murmurs coincide with the S heart sound. What action will help the nurse confirm the presence of this sound? Move the diaphragm of the stethoscope to the base of the heart. This action will not enable the nurse to hear the extra heart sound more effectively. Use the bell of the stethoscope to continue listening at the apical site. A soft dull sound heard after S2 is an abnormal heart sound. This S3 heart sound is low pitched and is heard best at the apex with the bell of the stethoscope. Palpate the apical impulse while listening at the base of the heart. This action will not enable the nurse to hear the extra heart sound more effectively. Place the bell of the stethoscope at the right sternal border at the third interspace. This action will not enable the nurse to hear the extra heart sound more effectively. - - correct ans- - Use the bell of the stethoscope to continue listening at the apical site. A soft dull sound heard after S2 is an abnormal heart sound. This S3 heart sound is low pitched and is heard best at the apex with the bell of the stethoscope. To inspect for jugular vein distention, what actions should the nurse take?
Palpate the pulsation again, using less pressure. Venous pulsations are not palpable. Reposition the client's head and attempt to palpate again. Venous pulsations are not palpable. Document the level at which the pulsation is observed. Venous pulsations are not palpable. The nurse should document the level at which the pulsations are observed. - - correct ans- - Document the level at which the pulsation is observed. Venous pulsations are not palpable. The nurse should document the level at which the pulsations are observed. What assessment should the nurse include? Check for jugular vein distention. An S3 heart sound may be an early indicator of the onset of heart failure, so the nurse should assess the client for other signs of heart failure, including jugular vein distention. Note the onset of nailbed clubbing. Nailbed clubbing is a sign of chronic hypoxemia, rather than a finding observed during an acute change in condition. Check for diminished skin elasticity. Decreased skin elasticity is typically related to loss of fluid volume. An S3 heart sound is not related to loss of fluid volume. Assess for orthostatic hypotension. The onset of an S3 heart sound is unlikely to be related to orthostatic hypotension. - - correct ans- - Check for jugular vein distention.
An S3 heart sound may be an early indicator of the onset of heart failure, so the nurse should assess the client for other signs of heart failure, including jugular vein distention The nurse does not hear a bruit. What should the nurse do next? Reassure the client that his right artery sounds "clear" and listen on the left side. The absence of a bruit does not always indicate absence of carotid occlusion. Listen at the base of the neck again, this time using the diaphragm of the stethoscope. The bell of the stethoscope is used to assess for a carotid bruit. Move the bell of the stethoscope up the right side of the neck to the mid-cervical area. The RN should auscultate each carotid artery systematically, including the base of the neck, the mid-cervical area, and the angle of the jaw. Press the bell of the stethoscope more firmly against the base of the neck and listen again. Placing the bell of the stethoscope more firmly may result in an artificial bruit. - - correct ans- - Move the bell of the stethoscope up the right side of the neck to the mid-cervical area. The RN should auscultate each carotid artery systematically, including the base of the neck, the mid-cervical area, and the angle of the jaw. Which assessment data are important for the nurse to report to the client's HCP? Presence of S1 and S2 heart sounds. This is a normal finding that does not need to be reported. Onset of an S3 heart sound.
