HESI RN Compass Exit Exam: Authentic Exam Questions and Answers with Expert-Verified Explanations for 2024

HESI RN Compass Exit Exam: Authentic Exam Questions and Answers with Expert-Verified Explanations for 2024 A male client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches the nurse notes a space of three finger widths between the top of the crutch and the clients axilla. What action should the nurse take? - ANSWER Proceed with teaching the client how to walk with crutches After experiencing symptoms caused by an abnormal heart rhythm a client is placed on a temporary pacemaker. When the client expresses concern and fear of the pacemaker how should the nurse respond? - ANSWER Encourage discussion about the concerns and fears Prior to initiating digital removal of fecal impaction it is important for the nurse to perform which assessment? - ANSWER Vital signs The mother of a child with tetralogy of Fallot asks the nurse "Why did this happen to my baby? What did I do wrong?" Which response is most helpful? - ANSWER This must be a very difficult time for you The healthcare provider prescribes bladder irrigation to maintain patency of a clients indwelling catheter. Which intervention should the nurse implement? - ANSWER Use sterile syringe to irrigate the normal saline 20ML The nurse assesses a client for a pulse deficit and counts an apical pulse for 72 bpm and a radial pulse of 88 bpm. What action should the nurse take? - ANSWER Obtain a second pulse deficit reading A female who is 1 day post mastectomy is crying when the nurse enter the room. What action should the nurse take? - ANSWER Stay with the client in silence touching her forearm A 24 hour urine collection is in progress. The client tells the nurse that the last voiding was accidentally flushed instead of saving in the container. What intervention should the nurse initiate? - ANSWER Discard the urine and start another 24 hour period A confused elderly male client is having trouble sleeping at night and is sometimes found wandering the hallway. What nursing intervention should the nurse implement first? - ANSWER Provide a backrub at bedtime A young male client with testicular cancer has a living will that describes his desire that no extraordinary measures be taken to save his life. The healthcare provider knows the client has a good prognosis and refuses to write a do not resuscitate prescription. What action should the nurse take? - ANSWER Initiate an ethics committee review of the case The nurse is preparing to feed a newly admitted elderly male client who is debilitated but is able to respond to most commands. Before starting to feed the client which information is most important for the nurse to obtain? - ANSWER Client's ability to chew and swallow The nurse enters the room of a client with C Diff infection to administer an intravenous antibiotic. The unlicensed assistive personnel is in the room cleaning the clients buttocks and states the client has been incontinent with diarrhea. The UAP is wearing gloves but not a gown. Which action should the nurse implement first? - ANSWER Tell the UAP to put a gown on The computer documentation system shuts down while the nurse is entering the client's physical assessment data. What should the nurse do first? - ANSWER Wait for notification services department of the situation In assessing a client who has a nursing diagnosis of spiritual distress. Which action should the nurse take first? - ANSWER Assist and support the client in establishing short term goals A policy requiring the removal of acrylic nails by all nursing personnel was implemented 6 months ago. Which assessment measure best determines if the intended outcome of the policy is being achieved? - ANSWER Healthcare associated infection rate The nurse explains to an older adult male the procedure for collecting a 24 hour urine specimen for creatine clearance. - ANSWER Empty the urinal into the 24 hour collection container A 54 year old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most effective - ANSWER Refer her to support group for family members dying of cancer A client who has a BMI of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend? - ANSWER Keep a record of food and drinks consumed daily The nurse assess a client who has a nasal cannula delivering oxygen at 2L/Min. To assess for skin damage related to the cannula which area should the nurse observe - ANSWER tops of ears, around the nostrils, and over the cheeks The nurse observes the unlicensed assistive personnel who is providing a total bed bath for a confused lethargic client. The UAP is soaking the clients foot in a basin of warm water placed in the bed. What action should the nurse take? - ANSWER Remind the UAP to dry between the toes completely The nurse in the Emergency Department observes a colleague viewing the EMR of a client who holds an elected position in the community. The client is not part of the colleague's assignment. Which action should the nurse implement? - ANSWER Communicate the colleague's actions to the unit charge nurse At 0100 on a male clients second postoperative night the client states he is unable to sleep and plans to read to feel sleepy. What action should the nurse implement - ANSWER Bring the client a prescribed PRN sedative-hypnotic The nursing staff in the Cardiovascular Intensive Care Unit are creating a continuous quality improvement project on social media that addresses coronary artery disease. Which action should the nurse implement to protect client privacy - ANSWER Remove identifying information of the clients who participated A male client with unstable angina needs a cardiac catherization so the healthcare provider explains the risks and the benefits of the procedure, and then leaves to set up for the procedure. When the nurse presents the consent form for signature the client hesitates and asks how the wires will keep his heart going. Which action should the nurse take? - ANSWER Postpone the procedure until the client understands the risks and benefits The nurse is teaching a client hot to do active range of motion ROM exercises. To exercise the hinge joints which action should the nurse instruct the client to perform? - ANSWER bend the arm by flexing the ulnar to the humerus A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What actions should the nurse take first - ANSWER Access the side effects of the medication When assessing a male client the nurse finds that he is fatigued and experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings the nurse plans to check the client's laboratory values to validate the existence of - ANSWER hypokalemia A female clients significant other has been at her bedside providing reassurance and support for the past 3 days as desired by the client. The clients estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement? - ANSWER Request a consultation with the ethics committee for resolution of the situation When measuring vital signs the nurse observes that a client is using accessory neck muscles during respirations. What follow up action should the nurse implement? - ANSWER Check for neck vein distention To avoid nerve injury, what location should the nurse select to administer a 3 mL IM injection? - ANSWER outer upper quadrant of the buttocks Which instruction should the nurse include in the discharge teaching plan of an adult with hypernatremia - ANSWER review food labels for sodium content While changing a client's postop dressing the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and foul odor. Given there is a positive MRSA which is the most important action for the nurse to take? - ANSWER Initiate contact precautions To prepare a client for the potential side effects of a newly prescribed medication What action should the nurse implement - ANSWER assess the client for health alterations that may be impacted by the effects of the medication An older adult male is admitted to the medical unit following a fall at home. When undressing him the nurse finds that he is wearing an adult diaper and skin breakdown is obvious over his sacral area. What action should the nurse implement first? - ANSWER Determine the size and depth of the skin breakdown over the sacral area A female client with chronic back pain has been taking muscle relaxants and analgesics to manage the discomfort, but is now experiencing an acute episode of pain that is not relieved by this medication regimen. The client tells the nurse she does not want to have back surgery for a herniated intervertebral disk, and reports that she has found acupuncture effective in resolving past acute episodes. Which response is best for the nurse to provide? - ANSWER Acupuncture is a complementary therapy that is often effective for management of pain The nurse is providing wound care to a client with a stage 3 pressure ulcer that has a large amount of eschar. The wound care prescription states "clean the wound and then apply collagenase" collagenase is a debriding agent. The prescription does not specify a cleansing method. Which technique should the nurse cleanse the pressure ulcer - ANSWER Irrigate the wound with sterile normal saline A client is admitted with a fever of unknown origin. To assess fever patterns which intervention should the nurse implement? - ANSWER Measure temperature at regular intervals When performing BP measurements to assess for orthostatic hypotension which action should the nurse implement first? - ANSWER Position the client supine for a few days The unlicensed assistive personnel describes the appearance of the bowel movement of several clients . Which description warrants additional follow up by the nurse - ANSWER - solid with red streaks -brown liquid -multiple hard pellets - tarry appearance A female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment she ahs not yet been fitted for a particulate filter mask. Which action should the nurse take - ANSWER Send the UAP to be fitted for a particulate filter mask so she can provide care to this client In home hospice care is arranged for a client with stage 4 lung cancer. While the palliative nurse is arranging for discharge the client verbalizes concerns about pain. What action should the nurse implement - ANSWER Provide client with a schedule of around the clock prescribed analgesic use What assessment finding places a client at risk for problems associated with impaired skin integrity - ANSWER Cap refill 5 seconds When evaluating the effectiveness of a clients nursing care the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take? - ANSWER Determine if the expected outcomes were realistic The nurse attaches a pulse oximeter to a clients fingers and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading - ANSWER 2+ edema to fingers and hands The nurse is caring for a hospitalized client who is placed in restraints due to confusion. The family removes the restraints while they are with the client. When the family leaves what action should the nurse take? - ANSWER Reassess the client to determine the need for continuing restraints The nurse is caring for a preadolescent client in skeletal dunlop traction. Which nursing intervention is appropriate for this client? - ANSWER Make certain the child is maintained in correct body alignment The nurse is assessing a healthy child at the 2 year check up. Which of the following should the nurse report immediately to the healthcare provider - ANSWER Height and weight percentiles vary widely The parents of a 2 year old child report that he has been holding his breath whenever he has temper tantrums. What is the best action by the nurse? - ANSWER Advise the parents ignore the breath holding because breathing will begin as a reflex The nurse is assessing a client in the emergency room. Which statement suggests that the problem is acute angina? - ANSWER My pain is deep in my chest behind my sternum Enalapril Maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering medication? - ANSWER Checking the clients blood pressure A client is scheduled to undergo an upper GI series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instructions? - ANSWER "I need to drink citrate of magnesia the night before the test and give myself a fleet enema on the morning of the test" A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the physician's answering service and is told the physician is off for the night and will be available in the morning. The nurse should - ANSWER Ask the answering service to contact the physician on call An emergency department nurse is monitoring a client with suspected acute myocardial infarction (MI) who is awaiting transfer to the Coronary Intensive Care Unit. The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the clients carotid pulse and determines the PVCs are not resulting in perfusion. The appropriate action by the nurse is to - ANSWER Ask the ED physician to check the client After receiving IV fluids in the Emergency Department and elderly client is admitted to the acute care with a medical diagnosis of dehydration. The client is receiving 0.9% normal saline at 125ml/hr via saline lock and has a bounding pulse, tachycardia, and pedal edema. When contacting the healthcare provider the nurse anticipates what intervention - ANSWER Remove the saline lock from the clients arm A client who is admitted to the care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse evaluate first? - ANSWER Evaluate swallow The nurse is preparing a client who had a below the knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client - ANSWER -wash the stump with soap and water -inspect the skin for redness -use a residual limb shrinker After 2 days treatment for dehydration, a child continues to vomit and have diarrhea. Normal saline is infusing, and the child's urine output is 50 mL/hour. During morning assessment, the nurse determines that the child is lethargic and difficult to arouse. Which action should the nurse implement? - ANSWER perform a fingerstick glucose test