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HESI RN · HESI Fundamentals of Nursing · EMT Vital Signs Assessment

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Showing all 5 practice questions with expert explanatory rationales.

Question 1 of 5

A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which action should the nurse take next?

A. Count the patient's respirations.

B. Percuss the thorax bilaterally, noting any differences in percussion tones.

C. Call for a chest x-ray and wait for the results before continuing the assessment.

D. Inspect the thorax for any new masses and bleeding associated with respirations.

Expert Explanatory Rationale

Correct Answer: Percuss the thorax bilaterally, noting any differences in percussion tones.

Question 2 of 5

The nurse is performing the Denver II screening test on a 12-month-old infant during a routine well-child visit. The nurse should tell the infant's parents that the Denver II:

A. Tests three areas of development: cognitive, physical, and psychological

B. Will indicate whether the child has a speech disorder so that treatment can begin

C. Is a screening instrument designed to detect children who are slow in development

D. Is a test to determine intellectual ability and may indicate whether problems will develop later in school

Expert Explanatory Rationale

Correct Answer: Is a screening instrument designed to detect children who are slow in development

Question 3 of 5

During the cardiac auscultation, the nurse hears a sound immediately occurring after the S2 at the second left intercostal space. To further assess this sound, what should the nurse do?

A. Have the patient turn to the left side while the nurse listens with the bell of the stethoscope.

B. Ask the patient to hold his or her breath while the nurse listens again.

C. No further assessment is needed because the nurse knows this sound is an S3.

D. Watch the patient's respirations while listening for the effect on the sound.

Expert Explanatory Rationale

Correct Answer: Watch the patient's respirations while listening for the effect on the sound.

Question 4 of 5

The nurse is performing a neurological assessment and asks the patient to squeeze their hands. Which of the following is being tested?

A. Cerebellar function.

B. Motor function and strength.

C. Sensory function.

D. Coordination.

Expert Explanatory Rationale

Correct Answer: Motor function and strength.

Question 5 of 5

A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for approximately 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing:

A. Claudication.

B. Sore muscles.

C. Muscle cramps.

D. Venous insufficiency.

Expert Explanatory Rationale

Correct Answer: Claudication.

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