HESI COMPASS MODULE EXAM 2 EXAM
SCRIPT 2026 ACUTE CARE NURSING
INTERVENTIONS COMPLETE SOLUTION
VIEW
◉ A nurse is assessing the carotid artery of a client with
cardiovascular disease. The nurse performs this assessment in
which manner?
A. Palpating the carotid artery in the upper third of the neck
B. Palpating both arteries simultaneously to compare amplitude
C. Listening to the carotid artery, using the bell of the stethoscope to
assess for bruits
D. Instructing the client to take slow, deep breaths while the nurse
listens to the carotid artery
Answer: C. Listening to the carotid artery, using the bell of the
stethoscope to assess for bruits
Rationale: To assess the carotid artery, the nurse uses the techniques
of palpation and auscultation. The nurse palpates each carotid
artery medial to the sternomastoid muscle in the neck. The nurse
should avoid putting pressure on the carotid sinus higher in the neck
because of the risk of excessive vagal stimulation, which could slow
the heart rate. The nurse should palpate one artery at a time to avoid
,compromising arterial blood flow to the brain. The nurse should
auscultate each carotid artery for the presence of a bruit. A bruit is a
blowing, swishing sound indicating blood flow turbulence; normally
a bruit is not present. The nurse should lightly place the bell of the
stethoscope over the carotid artery and ask the client to hold his or
her breath briefly so that tracheal breath sounds do not mask or
mimic a carotid artery bruit.
◉ A nurse is preparing to listen to the apical heart rate in the area of
the mitral valve in an adult client. The nurse should place the
stethoscope at which location on the client's chest?
A. Second left interspace
B. Second right interspace
C. Left lower sternal border
D. Fifth left interspace at the midclavicular line
Answer: D. Fifth left interspace at the midclavicular line
Rationale: The mitral valve is located in the area of the fifth left
interspace, at the midclavicular line. The pulmonic valve is located in
the area of the second left interspace. The aortic valve is located in
the area of the second right interspace. The tricuspid valve is located
in the area of the left lower sternal border.
◉ The nurse is observing a new nurse employee assess a client's
dorsalis pedis pulse. The nurse realizes the new nurse is using
correct technique if the nurse places the fingertips on which part of
the client's body?
,A. Behind the knee
B. Lateral to the extensor tendon of the big toe
C. In the groove between the malleolus and the Achilles tendon
D. Below the inguinal ligament, halfway between the pubis and the
anterior superior iliac spines
Answer: B. Lateral to the extensor tendon of the big toe
Rationale: The dorsalis pedis pulse is palpated lateral to and parallel
with the extensor tendon of the big toe. The popliteal pulse is
palpated behind the knee. The posterior tibial pulse is palpated in
the groove between the malleolus and the Achilles tendon. The
femoral artery is located below the inguinal ligament, halfway
between the pubis and the anterior superior iliac spines.
◉ A client with peripheral artery disease tells the nurse that pain
develops in his left calf when he is walking and subsides with rest.
The nurse determines the client is likely experiencing which
disorder?
A. Venous insufficiency
B. Intermittent claudication
C. Sore muscles from overexertion
D. Muscle cramps related to musculoskeletal problems
Answer: B. Intermittent claudication
, Rationale: Leg pain characteristic of peripheral artery disease is
known as intermittent claudication. Usually the client can walk only
a certain distance before cramping, burning, muscle discomfort, or
pain forces him or her to stop; the pain subsides after rest. When the
client resumes walking, he or she can walk the same distance before
the pain returns. The pain is reproducible. As the disease progresses,
the client walks shorter and shorter distances before pain recurs.
Ultimately pain may even occur while the client is at rest. Therefore
the other options are incorrect.
◉ A nurse conducting a peripheral vascular assessment performs
the Allen test. The nurse understands that this test is used to
determine the patency of which structures?
A. Capillaries
B. Pedal pulses
C. Femoral arteries
D. Radial and ulnar arteries
Answer: D. Radial and ulnar arteries
Rationale: The nurse would perform the Allen test to determine the
patency of the radial and ulnar arteries. The nurse applies direct
pressure over the client's ulnar and radial arteries simultaneously.
While the nurse is applying pressure, the client is asked to open and
close the hand repeatedly; the hand should blanch. The nurse then
releases pressure from the ulnar artery while compressing the radial
artery and assesses the color of the extremity distal to the pressure
SCRIPT 2026 ACUTE CARE NURSING
INTERVENTIONS COMPLETE SOLUTION
VIEW
◉ A nurse is assessing the carotid artery of a client with
cardiovascular disease. The nurse performs this assessment in
which manner?
A. Palpating the carotid artery in the upper third of the neck
B. Palpating both arteries simultaneously to compare amplitude
C. Listening to the carotid artery, using the bell of the stethoscope to
assess for bruits
D. Instructing the client to take slow, deep breaths while the nurse
listens to the carotid artery
Answer: C. Listening to the carotid artery, using the bell of the
stethoscope to assess for bruits
Rationale: To assess the carotid artery, the nurse uses the techniques
of palpation and auscultation. The nurse palpates each carotid
artery medial to the sternomastoid muscle in the neck. The nurse
should avoid putting pressure on the carotid sinus higher in the neck
because of the risk of excessive vagal stimulation, which could slow
the heart rate. The nurse should palpate one artery at a time to avoid
,compromising arterial blood flow to the brain. The nurse should
auscultate each carotid artery for the presence of a bruit. A bruit is a
blowing, swishing sound indicating blood flow turbulence; normally
a bruit is not present. The nurse should lightly place the bell of the
stethoscope over the carotid artery and ask the client to hold his or
her breath briefly so that tracheal breath sounds do not mask or
mimic a carotid artery bruit.
◉ A nurse is preparing to listen to the apical heart rate in the area of
the mitral valve in an adult client. The nurse should place the
stethoscope at which location on the client's chest?
A. Second left interspace
B. Second right interspace
C. Left lower sternal border
D. Fifth left interspace at the midclavicular line
Answer: D. Fifth left interspace at the midclavicular line
Rationale: The mitral valve is located in the area of the fifth left
interspace, at the midclavicular line. The pulmonic valve is located in
the area of the second left interspace. The aortic valve is located in
the area of the second right interspace. The tricuspid valve is located
in the area of the left lower sternal border.
◉ The nurse is observing a new nurse employee assess a client's
dorsalis pedis pulse. The nurse realizes the new nurse is using
correct technique if the nurse places the fingertips on which part of
the client's body?
,A. Behind the knee
B. Lateral to the extensor tendon of the big toe
C. In the groove between the malleolus and the Achilles tendon
D. Below the inguinal ligament, halfway between the pubis and the
anterior superior iliac spines
Answer: B. Lateral to the extensor tendon of the big toe
Rationale: The dorsalis pedis pulse is palpated lateral to and parallel
with the extensor tendon of the big toe. The popliteal pulse is
palpated behind the knee. The posterior tibial pulse is palpated in
the groove between the malleolus and the Achilles tendon. The
femoral artery is located below the inguinal ligament, halfway
between the pubis and the anterior superior iliac spines.
◉ A client with peripheral artery disease tells the nurse that pain
develops in his left calf when he is walking and subsides with rest.
The nurse determines the client is likely experiencing which
disorder?
A. Venous insufficiency
B. Intermittent claudication
C. Sore muscles from overexertion
D. Muscle cramps related to musculoskeletal problems
Answer: B. Intermittent claudication
, Rationale: Leg pain characteristic of peripheral artery disease is
known as intermittent claudication. Usually the client can walk only
a certain distance before cramping, burning, muscle discomfort, or
pain forces him or her to stop; the pain subsides after rest. When the
client resumes walking, he or she can walk the same distance before
the pain returns. The pain is reproducible. As the disease progresses,
the client walks shorter and shorter distances before pain recurs.
Ultimately pain may even occur while the client is at rest. Therefore
the other options are incorrect.
◉ A nurse conducting a peripheral vascular assessment performs
the Allen test. The nurse understands that this test is used to
determine the patency of which structures?
A. Capillaries
B. Pedal pulses
C. Femoral arteries
D. Radial and ulnar arteries
Answer: D. Radial and ulnar arteries
Rationale: The nurse would perform the Allen test to determine the
patency of the radial and ulnar arteries. The nurse applies direct
pressure over the client's ulnar and radial arteries simultaneously.
While the nurse is applying pressure, the client is asked to open and
close the hand repeatedly; the hand should blanch. The nurse then
releases pressure from the ulnar artery while compressing the radial
artery and assesses the color of the extremity distal to the pressure
