Compass HESI module 9 Mock Test
Papers With Already Passed Solutions
Scored A+.
A client who has undergone abdominal surgery calls the nurse and reports that she just felt
"something give way" in the abdominal incision. The nurse checks the incision and notes the
presence of wound dehiscence. The nurse should take which immediate action?
Document the findings
Contact the primary health care provider
Place the client in a supine position with the legs flat
Cover the abdominal wound with a sterile dressing moistened with sterile saline solution -
Answer Cover the abdominal wound with a sterile dressing moistened with sterile saline
solution
A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is
restless and the pulse rate is increased. As the nurse continues the assessment, the client begins
to vomit a copious amount of bright-red blood. The nurse should take which immediate action?
Notify the surgeon
Continue the assessment
Check the client's blood pressure
Obtain a flashlight, gauze, and a curved hemostat - Answer Notify the surgeon
A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and
tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets
about to take which action?
Preparing the client for a perfusion scan
Attaching the client to a cardiac monitor
Administering oxygen by way of nasal cannula
Ensuring that the intravenous (IV) line is patent - Answer Administering oxygen by way of nasal
cannula
A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes
constant bubbling in the water seal chamber. What actions should the nurse take? Select all that
apply.
,Document assessment findings, actions taken, and client response - Answer Assess the system
for an external air leak
Document assessment findings, actions taken, and client response
A nurse is helping a client with a closed chest tube drainage system get out of bed and into a
chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the
insertion site. What is the immediate nursing action?
Reinsert the chest tube
Contact the primary health care provider
Transfer the client back to bed
Cover the insertion site with a sterile occlusive dressing - Answer Cover the insertion site with
a sterile occlusive dressing
A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody
secretions. Which action should the nurse take first?
Continue suctioning to remove the blood
Check the degree of suction being applied
Encourage the client to cough out the bloody secretions
Remove the suction catheter from the client's nose and begin vigorous suctioning through the
mouth - Answer Check the degree of suction being applied
A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client
begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheter
from the client's trachea but is unable to do so. Which action should the nurse take first?
Call a code
Contact the primary health care provider
Administer a bronchodilator
Disconnect the suction source from the catheter - Answer Disconnect the suction source from
the catheter
A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy
24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour.
Which action should the nurse take first?
Contact the primary health care provider
Check for kinks in the drainage system
, A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client's
urine output for the past hour was 25 mL. On the basis of this finding, the nurse should take
which action first?
Call the primary health care provider
Increase the rate of the IV infusion
Check the client's overall intake and output record
Administer a 250-mL bolus of normal saline solution (0.9%) - Answer Check the client's overall
intake and output record
A nurse is getting a client out of bed for the first time since surgery. The nurse raises the head of
the bed, and the client complains of dizziness. Which action should the nurse take first?
Check the client's blood pressure
Check the oxygen saturation level
Have the client take some deep breaths
Lower the head of the bed slowly until the dizziness is relieved - Answer Lower the head of the
bed slowly until the dizziness is relieved
A nurse is preparing for intershift report when an assistive personnel (AP) pulls an emergency
call light in a client's room. Upon answering the light, the nurse finds a client who returned from
surgery earlier in the day experiencing tachycardia and tachypnea. The client's blood pressure is
88/60 mm Hg. Which action should the nurse take first?
Call the primary health care provider
Check the hourly urine output
Check the IV site for infiltration
Place the client in a modified Trendelenburg position - Answer Place the client in a modified
Trendelenburg position
A nurse is assessing the chest tube drainage system of a postoperative client who has
undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody
drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after
the initial assessment, the nurse notes that the bubbling in the water seal chamber is now
constant, and the client appears dyspneic. On the basis of these findings, what should the nurse
assess first?
The client's vital signs
The amount of drainage
The client's lung sounds
Papers With Already Passed Solutions
Scored A+.
A client who has undergone abdominal surgery calls the nurse and reports that she just felt
"something give way" in the abdominal incision. The nurse checks the incision and notes the
presence of wound dehiscence. The nurse should take which immediate action?
Document the findings
Contact the primary health care provider
Place the client in a supine position with the legs flat
Cover the abdominal wound with a sterile dressing moistened with sterile saline solution -
Answer Cover the abdominal wound with a sterile dressing moistened with sterile saline
solution
A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is
restless and the pulse rate is increased. As the nurse continues the assessment, the client begins
to vomit a copious amount of bright-red blood. The nurse should take which immediate action?
Notify the surgeon
Continue the assessment
Check the client's blood pressure
Obtain a flashlight, gauze, and a curved hemostat - Answer Notify the surgeon
A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and
tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets
about to take which action?
Preparing the client for a perfusion scan
Attaching the client to a cardiac monitor
Administering oxygen by way of nasal cannula
Ensuring that the intravenous (IV) line is patent - Answer Administering oxygen by way of nasal
cannula
A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes
constant bubbling in the water seal chamber. What actions should the nurse take? Select all that
apply.
,Document assessment findings, actions taken, and client response - Answer Assess the system
for an external air leak
Document assessment findings, actions taken, and client response
A nurse is helping a client with a closed chest tube drainage system get out of bed and into a
chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the
insertion site. What is the immediate nursing action?
Reinsert the chest tube
Contact the primary health care provider
Transfer the client back to bed
Cover the insertion site with a sterile occlusive dressing - Answer Cover the insertion site with
a sterile occlusive dressing
A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody
secretions. Which action should the nurse take first?
Continue suctioning to remove the blood
Check the degree of suction being applied
Encourage the client to cough out the bloody secretions
Remove the suction catheter from the client's nose and begin vigorous suctioning through the
mouth - Answer Check the degree of suction being applied
A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client
begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheter
from the client's trachea but is unable to do so. Which action should the nurse take first?
Call a code
Contact the primary health care provider
Administer a bronchodilator
Disconnect the suction source from the catheter - Answer Disconnect the suction source from
the catheter
A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy
24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour.
Which action should the nurse take first?
Contact the primary health care provider
Check for kinks in the drainage system
, A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client's
urine output for the past hour was 25 mL. On the basis of this finding, the nurse should take
which action first?
Call the primary health care provider
Increase the rate of the IV infusion
Check the client's overall intake and output record
Administer a 250-mL bolus of normal saline solution (0.9%) - Answer Check the client's overall
intake and output record
A nurse is getting a client out of bed for the first time since surgery. The nurse raises the head of
the bed, and the client complains of dizziness. Which action should the nurse take first?
Check the client's blood pressure
Check the oxygen saturation level
Have the client take some deep breaths
Lower the head of the bed slowly until the dizziness is relieved - Answer Lower the head of the
bed slowly until the dizziness is relieved
A nurse is preparing for intershift report when an assistive personnel (AP) pulls an emergency
call light in a client's room. Upon answering the light, the nurse finds a client who returned from
surgery earlier in the day experiencing tachycardia and tachypnea. The client's blood pressure is
88/60 mm Hg. Which action should the nurse take first?
Call the primary health care provider
Check the hourly urine output
Check the IV site for infiltration
Place the client in a modified Trendelenburg position - Answer Place the client in a modified
Trendelenburg position
A nurse is assessing the chest tube drainage system of a postoperative client who has
undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody
drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after
the initial assessment, the nurse notes that the bubbling in the water seal chamber is now
constant, and the client appears dyspneic. On the basis of these findings, what should the nurse
assess first?
The client's vital signs
The amount of drainage
The client's lung sounds
