HESI RN COMPASS EXIT 2023 EXAM V1 QUESTIONS & ANSWERS LATEST UPDATE

HESI RN COMPASS EXIT EXAM V1 1. The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing intervention is appropriate for this child? A) Make certain the child is maintained in correct body alignment. 2. The nurse is assessing a healthy child at the 2 year check up. Which of the following should the nurse report immediately to the health care provider? A) Height and weight percentiles vary widely 3. 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? C) Advise the parents to ignore breath holding because breathing will begin as a reflex 4. The nurse is assessing a client in the emergency room. Which statement suggests that the problem is acute angina? A) "My pain is deep in my chest behind my sternum." 5. Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication? A. Checking the client's blood pressure 6. A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction? C. "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test." 7. 2-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 that the physician is off for the night and will be available in the morning. The nurse should: B. Ask the answering service to contact the on-call physician 8. An emergency department (ED) 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 client's carotid pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action by the nurse is: B. Asking the ED physician to check the client Correct 9. NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client's record and notes that the client routinely takes an oral antihypertensive medication each morning. The nurse should: A. Administer the antihypertensive with a small sip of water 10. A client who recently underwent coronary artery bypass graft surgery comes to the physician's office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response by the nurse is therapeutic? A. "Tell me more about what you’re feeling." 11. A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which of the following actions should be the nurse’s priority? A. Contacting the physician 12. A nurse has assisted a physician in inserting a central venous access device into a client with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion of the catheter, the nurse immediately plans to: A. Call the radiography department to obtain a chest x-ray 13. The nurse is has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis? D) Safety 14. While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development at this age? B) They are able to think logically in organizing facts 15. A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to B) An occupational therapist from the community center 16. A priority goal of involuntary hospitalization of the severely mentally ill client is C) Protection from harm to self or others 17. The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend A) Isometric 18. The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report A) Loss of consciousness 19. A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would C) Administer a laxative to the client the evening before the examination 20. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What is the priority nursing diagnoses at this time? D) Risk for infection 21. The parents of a newborn male with hypospadias want their child circumcised. The best response by the nurse is to inform them that A) Circumcision is delayed so the foreskin can be used for the surgical repair 22. The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect? C) Shallow respirations 23. A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the nurse’s best explanation of these findings? A) These side effects are common and should subside in a few days 24. A 57 year-old male client has a hemoglobin of 10 mg/dl and a hematocrit of 32%. What would be the most appropriate follow-up by the home care nurse? A) Ask the client if he has noticed any bleeding or dark stools . 25. A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is the C) Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow 26. For a 6 year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate? A) Institute seizure precautions 27. Following mitral valve replacement surgery a client develops PVC’s. The health care provider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mgm/minute. The IV solution contains 2 grams of Lidocaine in 500 cc’s of D5W. The infusion pump delivers 60 micro drops/cc. What rate would deliver 4 mgm of Lidocaine/ minute? A) 60 microdrops/minute 28. The nurse is taking a health history from parents of a child admitted with possible Reye's Syndrome. Which recent illness would the nurse recognize as increasing the risk to develop Reye's Syndrome? C) Varicella 29. While giving care to a 2 year-old client, the nurse should remember that the toddler's tendency to say "no" to almost everything is an indication of what psychosocialskill? D) Assertion of control 30. A postpartum client admits to alcohol use throughout the pregnancy. Which of the following newborn assessments suggests to the nurse that the infant has fetal alcohol syndrome? C) Cranial facial abnormalities are noted 31. The nurse is attending a workshop about caring for persons infected with Hepatitis. Which statement is correct when referring to the incidence rate for Hepatitis? A) The number of persons in a population who develop Hepatitis B during a specific period of time 32. A 36 year-old female client has a hemoglobin level of 14 g/dl and a hematocrit of 42% following a D&C. Which of the following would the nurse expect to find when assessing this client? A) Capillary refill less than 3 seconds 33. The nurse is caring for a client suspected to have Tuberculosis (TB). Which of the following diagnostic tests is essential for determining the presence of active TB? The nurse is caring for a client suspected to have Tuberculosis (TB). Which of the following diagnostic tests is essential for determining the presence of active TB? B) Sputum culture 34. The nurse has been teaching an apprehensive primipara who has difficulty in initial nursing of the newborn. What observation at the time of discharge suggests that initial breast feeding is effective? A) The mother feels calmer and talks to the baby while nursing 35. The mother of a burned child asks the nurse to clarify what is meant by a third degree burn. The best response by the nurse is C) "All layers of the skin were destroyed in the burn." 36. The nurse is taking a health history from a Native American client. It is critical that the nurse must remember that eye contact with such clients is considered B) Rude 37. A nurse is instructing a class for new parents at a local community center. The nurse would stress that which activity is most hazardous for an 8 month-old child? D) Eating peanuts 38. When teaching parents about sickle cell disease, the nurse should tell them that their child's anemia is caused by B) An imbalance between red cell destruction and production 39. The nurse is assessing a newborn delivered at home by an admitted heroin addict. Which of the following would the nurse expect to observe? D) Jitteriness at 24-48 hours 40. The nurse is caring for a client with congestive heart failure. Which finding requires the nurse's immediate attention? A) Pulse oximetry of 85% 41. The nurse is assessing a young child at a clinic visit for a mild respiratory infection. Koplik spots are noted on the oral mucous membranes. The nurse should then assess which area of the body? A) Inspect the skin 42. Which action is most likely to ensure the safety of the nurse while making a home visit? C) Remain alert at all times and leave if cues suggest the home is not safe 43. An adolescent client is admitted in respiratory alkalosis following aspirin overdose. The nurse recognizes that this imbalance was caused by A) Tachypnea 44. The nurse discovers that the parents of a 2 year-old child continue to use an apnea monitor each night. The parents state: “We are concerned about the possible occurrence of sudden infant death syndrome (SIDS).” In order to take appropriate action, the nurse must understand that D) 95% of SIDS cases occur before 6 months of age 45. As a client is being discharged following resolution of a spontaneous pneumothorax, he tells the nurse that he is now going to Hawaii for a vacation. The nurse would warn him to avoid B) Scuba diving 46. The nurse is providing diet instruction to the parents of a child with cystic fibrosis. The nurse would emphasize that the diet should be C) High protein, high calorie, unrestricted fat 47. A client had arrived in the USA from a developing country 1 week prior. The client is to be admitted to the medical surgical unit with a diagnosis of AIDS with a history of unintended weight loss, drug abuse, night sweats, productive cough and a "feeling of being hot all the time." The nurse should assign the client to share a room with a client with the diagnosis of A) Acute tuberculosis with a productive cough of discolored sputum for over three months 48. A client's admission urinalysis shows the specific gravity value of 1.039. Which of the following assessment data would the nurse expect to find when assessing this client? C) Poor skin turgor 49. When teaching effective stress management techniques to a client 1 hour before surgery, which of the following should the nurse recommend? B) Deep breathing 50. When observing 4 year-old children playing in the hospital playroom, what activity would the nurse expect to see the children participating in? D) Playing cooperatively with other preschoolers 51. The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate finding? A) Hold a rattle 52. When teaching a 10 year-old child about their impending heart surgery, which form of explanation meets the developmental needs of this age child? D) Explain the surgery using a model of the heart 53. The parents of a child who has suddenly been hospitalized for an acute illness state that they should have taken the child to the pediatrician earlier. Which approach by the nurse is best when dealing with the parents' comments? D) Accept their feelings without judgment 54. When caring for a client with total parenteral nutrition (TPN), what is the most important action on the part of the nurse? C) Sterile technique for dressing change at IV site 55. When caring for a client who is receiving a thrombolytic agent to open a clot occluded coronary artery after a myocardial infarction, which finding would be of greatest concern to the nurse? B) Hematemesis 56. A 52 year-old client is being transfused with one unit of packed cells. A half hour after the transfusion was initiated, the client complains of chills and headache. Which action should the nurse implement first? C) Stop the transfusion 57. An adolescent client is hospitalized with menarthrosis from a Hemophilia A bleeding episode. Which order should be questioned by the nurse? C) Aspirin for pain management 58. The nurse is giving instructions to the mother of a newborn infant with oral candidiasis. Which statement by the mother would indicate the need for further teaching? D) "The therapy can be discontinued when the spots disappear." 59. The nurse is preparing a client for discharge following in-patient treatment for pulmonary tuberculosis. Which of these instructions should be given to the client? B) Continue medication use as prescribed 60. The nurse is administering an intravenous piggyback infusion of penicillin. Which of the following client statements would require the nurse's immediate attention? C) "I am itching all over." 61. A woman diagnosed with bipolar disorder is to take lithium (Lithane) as part of the treatment. What should the nurse discuss with the client as part of the teaching plan?C) Avoidance of alcohol 62. The nurse prepares to administer eye drops to a 6 year-old child. Which of these demonstrates the correct method for instillation of eye drops? D) In the conjunctival sac as the lower lid is pulled down 63. A depressed client is experiencing severe insomnia. The health care provider orders trazadone (Desyrel). The nurse tells the client to expect B) Relief of insomnia 64. A client with diabetes has a blood sugar is 306 this morning. After the nurse reports this lab result and the client's symptoms of excessive hunger and thirst, what would the nurse expect the health care provider to order? B) Regular insulin 65. The nurse is planning to administer otic drops to a 6 year-old child. Which of the following is the correct procedure? A) Hold the pinna up and back to instill the drops 66. A 1 year-old child is receiving temporary total parental nutrition (TPN) through a central venous line. This is the first day of TPN therapy. Although all of the following nursing actions must be included in the plan of care of this child, which one would be a priority at this time? C) Monitor serum glucose levels 67. Today's prothrombin time for a client receiving Coumadin is 20 (normal range listed by the lab is 10-14). What is the appropriate nursing action? B) Recognize that this is a therapeutic level 68. The nurse administered intravenous gamma globulin to an 18 month-old child with AIDS. The parent asks why this medication is being given. What is the nurse’s best response? C) "This medication is used to prevent bacterial infections." 69. The nurse is administering the initial total parenteral nutrition solution to a client. Which of the following assessments requires the nurse's immediate attention? D) Blood glucose of 350 mg/dl 70. The nurse is teaching a client with asthma about the correct use of the Azmacort (triamcinolone) inhaler. Which of the following statements, if made by the client, would indicate that the teaching was effective? B) "I should rinse my mouth after using the inhaler." 71. A client is admitted to the hospital because of heart failure and digoxin toxicity. At home, the client was taking digoxin (Lanoxin) and furosemide (Lasix). Which symptom would the nurse anticipate finding on the initial assessment? A) Muscle weakness and cramping 72. The nurse admits a client with hypertension who complains of dizziness after taking diltiazem (Cardizem). Which of the following is the most important information for the nurse to assess? A) Schedule for taking medicine 73. Which of the following classifications of medications would be most often used for clients with schizophrenia? D) Neuroleptics 74. Which response by the nurse would best assist the chemically impaired client to deal with issues of guilt? B) "What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?" 75. A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d.. The client’s family is alarmed and calls the clinic when "his eyes rolled upward." The nurse recognizes this as what type of side effect? A) Oculogyric crisis 76. Which of the following measures would be appropriate for the nurse to teach the parent of a nine month-old infant about diaper dermatitis? D) Discontinue a new food that was added to the infant's diet just prior to the rash 77. A mother brings her 26 month-old to the well-child clinic. She expresses frustration and anger due to her child's constantly saying "no" and his refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need? C) Independence 78. Which behavioral characteristic describes the domestic abuser? D) Low self-esteem 79. Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing D) "By prolonging breathing out with pursed lips the little areas in my lungs don't collapse." 80. During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem? C) "I have to turn my head to see my room." 81. A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of "suppression"? A) "I don't remember anything about what happened to me." 82. While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action? B) Massage the fundus 83. An infant weighed 7 pounds 8 ounces at birth. If growth occurs at a normal rate, what would be the expected weight at 6 months of age? A) Double the birth weight 84. On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse’s initial response should be to B) Introduce him/herself and accompany the client to the client’s room 85. A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client A) Has increased airway obstruction 86. A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse? A) "Focus on your sons' needs during the first days at home." 87. A 16 year-old client is admitted to a psychiatric unit with a diagnosis of attempted suicide. The nurse is aware that the most frequent cause for suicide in adolescents is D) Feelings of alienation or isolation 88. A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize B) Administration of thyroid hormone will prevent problems 89. A Hispanic client refuses emergency room treatment until a curandero is called. Thenurse understands that this person brings what to situations of illness? A) Holistic healing 90. In addition to disturbances in mental awareness and orientation, a client with cognitive impairment is also likely to show loss of ability in C) Learning, creativity, and judgment 91. In a long term rehabilitation care unit a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television in the assigned room. Further assessment by the nurse reveals excessive sweating, a splotchy doesn't contain sperm, continue to use another form of contraception. rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should do which action next? C) Check the client for bladder distention and the client's urinary catheter for kinks 92. The nurse is performing a physical assessment on a client with insulin dependent diabetes mellitus. Which client complaint calls for immediate nursing action? A) Diaphoresis and shakiness 93. The nurse is teaching a client about the healthy use of ego defense mechanisms. An appropriate goal for this client would be A) Reduce fear and protect self-esteem 94 In reviewing the assessment data of a client suspected of having diabetes insipidus, the nurse expects which of the following after a water deprivation test? B) Unchanged urine specific gravity 95. The nurse is evaluating the growth and development of a toddler with AIDS. The nurse would anticipate finding that the child has D) Delay in achievement of most developmental milestones 96. A client was admitted with a diagnosis of pneumonia. When auscultating the client's breath sounds, the nurse hears inspiratory crackles in the right base. Temperature is 102.3 degrees Fahrenheit orally. What finding would the nurse expect? D) Hypotension 97. A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse? A) Until the health care provider has determined that your ejaculate 98. A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture? C) The flow of life is believed to flow through major pathways or nerve clusters in your body. 99. The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect? C) Kawasaki disease occurs most often in boys, children younger than age 5 and children of Hispanic descen