HESI RN COMPASS EXIT EXAM V2
2024/2025 WITH CORRECT ANSWERS
A+
r the nurse to include in the client's discharge teaching
plan? - ANSWER-Report any signs of cloudy urine output.
After repositioning an immobile client, the nurse
observes an area of hyperemia. To assess for blanching,
what action should the nurse take? - ANSWER-Apply
light pressure over the area.
The nurse enters a client's room and observes the
client's wrist restraint secured as seen in the picture.
What action should the nurse take? - ANSWER-
Reposition the restraint tie onto the bedframe.
,A female client with acute respiratory distress syndrome
(ARDS) is chemically paralyzed and sedated while she is
on as assist-control ventilator using 50% FIO2. Which
assessment finding warrants
immediate intervention by the nurse? - ANSWER-
Diminished left lower lobe sounds
Rationale: Diminished lobe sounds indicate collapsed
alveoli or tension pneumothorax, which required
immediate chest tube insertion to re-inflate the lung.
The development of atherosclerosis is a process of
sequential events. Arrange the pathophysiological
events in orders of occurrence. (Place the first event on
top and the last on the bottom) - ANSWER-Arterial
endothelium injury causes inflammation
Macrophages consume low density lipoprotein (LDL),
creating foam cells
Foam cells release growth factors for smooth muscle
cells
Smooth muscle grows over fatty streaks creating fibrous
plaques
Vessel narrowing results in ischemia
Following a motor vehicle collision, an adult female with
a ruptured spleen and a blood pressure of 70/44, had an
emergency splenectomy. Twelve hours after the surgery,
her urine output is 25 ml/hour for the last two hours.
What pathophysiological reason supports the nurse's
decision to report this finding to the healthcare provider?
,- ANSWER-Oliguria signals tubular necrosis related to
hypoperfusion
A nurse-manager is preparing the curricula for a class for
charge nurses. A staffing formula based on what data
ensures quality client care and is most cost-effective? -
ANSWER-Skills of staff and client acuity
When performing postural drainage on a client with
Chronic Obstructive Pulmonary Disease (COPD), which
approach should the nurse use? - ANSWER-Explain that
the client may be placed in five positions
A client presents in the emergency room with right-
sided facial asymmetry. The nurse asks the client to
perform a series of movements that require use of the
facial muscles. What symptoms suggest that the client
has most likely experience a Bell's palsy rather than a
stroke? - ANSWER-Inability to close the affected eye,
raise brow, or smile
The nurse is teaching a client how to perform colostomy
irrigations. When observing the client's return
demonstration, which action indicated that the client
understood the teaching? - ANSWER-Keeps the irrigating
container less than 18 inches above the stoma
The nurse should teach the client to observe which
precaution while taking dronedarone? - ANSWER-Avoid
grapefruits and its juice
, A client who sustained a head injury following an
automobile collision is admitted to the hospital. The
nurse include the client's risk for developing increased
intracranial pressure (ICP) in the plan of care. Which
signs indicate to the nurse that ICP has increased? -
ANSWER-Increased Glasgow coma scale score.
Nuchal rigidity and papilledema.
Confusion and papilledema
Periorbital ecchymosis.
Rationale: papilledema is always an indicator of
increased ICP, and confusion is usually the first sign of
increased ICP. Other options do not necessarily reflect
increased ICP.
The nurse is caring for a client receiving continuous IV
fluids through a single lumen central venous catheter
(CVC). Based on the CVC care bundle, which action
should be completed daily to reduce the
risk for infection? - ANSWER-Confirm the necessity for
continued use of the CVC.
During an annual physical examination, an older
woman's fasting blood sugar (FBS) is determined to be
140 mg/dl or 7.8 mmol/L (SI). Which additional finding
obtained during a follow-up visit 2 weeks later is most
indicative that the client has diabetes mellitus (DM)? -
ANSWER-Repeated fasting blood sugar (FBS) is 132
mg/dl or 7.4 mmol/L (SI).
2024/2025 WITH CORRECT ANSWERS
A+
r the nurse to include in the client's discharge teaching
plan? - ANSWER-Report any signs of cloudy urine output.
After repositioning an immobile client, the nurse
observes an area of hyperemia. To assess for blanching,
what action should the nurse take? - ANSWER-Apply
light pressure over the area.
The nurse enters a client's room and observes the
client's wrist restraint secured as seen in the picture.
What action should the nurse take? - ANSWER-
Reposition the restraint tie onto the bedframe.
,A female client with acute respiratory distress syndrome
(ARDS) is chemically paralyzed and sedated while she is
on as assist-control ventilator using 50% FIO2. Which
assessment finding warrants
immediate intervention by the nurse? - ANSWER-
Diminished left lower lobe sounds
Rationale: Diminished lobe sounds indicate collapsed
alveoli or tension pneumothorax, which required
immediate chest tube insertion to re-inflate the lung.
The development of atherosclerosis is a process of
sequential events. Arrange the pathophysiological
events in orders of occurrence. (Place the first event on
top and the last on the bottom) - ANSWER-Arterial
endothelium injury causes inflammation
Macrophages consume low density lipoprotein (LDL),
creating foam cells
Foam cells release growth factors for smooth muscle
cells
Smooth muscle grows over fatty streaks creating fibrous
plaques
Vessel narrowing results in ischemia
Following a motor vehicle collision, an adult female with
a ruptured spleen and a blood pressure of 70/44, had an
emergency splenectomy. Twelve hours after the surgery,
her urine output is 25 ml/hour for the last two hours.
What pathophysiological reason supports the nurse's
decision to report this finding to the healthcare provider?
,- ANSWER-Oliguria signals tubular necrosis related to
hypoperfusion
A nurse-manager is preparing the curricula for a class for
charge nurses. A staffing formula based on what data
ensures quality client care and is most cost-effective? -
ANSWER-Skills of staff and client acuity
When performing postural drainage on a client with
Chronic Obstructive Pulmonary Disease (COPD), which
approach should the nurse use? - ANSWER-Explain that
the client may be placed in five positions
A client presents in the emergency room with right-
sided facial asymmetry. The nurse asks the client to
perform a series of movements that require use of the
facial muscles. What symptoms suggest that the client
has most likely experience a Bell's palsy rather than a
stroke? - ANSWER-Inability to close the affected eye,
raise brow, or smile
The nurse is teaching a client how to perform colostomy
irrigations. When observing the client's return
demonstration, which action indicated that the client
understood the teaching? - ANSWER-Keeps the irrigating
container less than 18 inches above the stoma
The nurse should teach the client to observe which
precaution while taking dronedarone? - ANSWER-Avoid
grapefruits and its juice
, A client who sustained a head injury following an
automobile collision is admitted to the hospital. The
nurse include the client's risk for developing increased
intracranial pressure (ICP) in the plan of care. Which
signs indicate to the nurse that ICP has increased? -
ANSWER-Increased Glasgow coma scale score.
Nuchal rigidity and papilledema.
Confusion and papilledema
Periorbital ecchymosis.
Rationale: papilledema is always an indicator of
increased ICP, and confusion is usually the first sign of
increased ICP. Other options do not necessarily reflect
increased ICP.
The nurse is caring for a client receiving continuous IV
fluids through a single lumen central venous catheter
(CVC). Based on the CVC care bundle, which action
should be completed daily to reduce the
risk for infection? - ANSWER-Confirm the necessity for
continued use of the CVC.
During an annual physical examination, an older
woman's fasting blood sugar (FBS) is determined to be
140 mg/dl or 7.8 mmol/L (SI). Which additional finding
obtained during a follow-up visit 2 weeks later is most
indicative that the client has diabetes mellitus (DM)? -
ANSWER-Repeated fasting blood sugar (FBS) is 132
mg/dl or 7.4 mmol/L (SI).
