HESI COMPASS COMPREHENSIVE EXIT
EXAM 2 QUESTIONS AND CORRECT
ANSWERS (VERIFIED ANSWERS) PLUS
RATIONALES 2025
1. A nurse is caring for a client with a serum potassium level of 2.9 mEq/L.
Which intervention is most appropriate?
A. Administer potassium chloride IV push
B. Administer potassium chloride IV diluted in NS
C. Restrict potassium intake
D. Monitor for hyperkalemia symptoms
IV potassium must be diluted and administered slowly to prevent cardiac
complications. A serum potassium of 2.9 mEq/L indicates hypokalemia.
2. Which task can the RN safely delegate to an unlicensed assistive
personnel (UAP)?
A. Teaching incentive spirometry
,B. Performing initial pain assessment
C. Interpreting blood glucose levels
D. Ambulating a stable post-op client
UAPs can assist with ambulation of stable patients. Teaching and
assessment require RN expertise.
3. A client with COPD is receiving oxygen therapy. Which oxygen delivery
system is most appropriate?
A. Non-rebreather mask at 15 L/min
B. Simple face mask at 10 L/min
C. Nasal cannula at 2 L/min
D. Venturi mask at 60%
Clients with COPD retain CO₂ and should receive low-flow oxygen to
prevent respiratory depression.
4. What is the priority nursing action for a client experiencing chest pain
unrelieved by rest?
A. Administer antacids
B. Administer prescribed nitroglycerin
C. Call the rapid response team
D. Monitor pain for 30 minutes
Nitroglycerin is the first-line treatment for angina. It dilates coronary
arteries and relieves pain.
,5. Which lab value indicates effective warfarin therapy?
A. INR 1.0
B. INR 2.5
C. INR 4.5
D. INR 0.8
An INR of 2.0 to 3.0 indicates therapeutic warfarin levels for most
indications.
6. A nurse suspects elder abuse. What is the most appropriate action?
A. Discuss suspicions with family
B. Report findings to Adult Protective Services
C. Document concern in hidden notes
D. Wait for more evidence
Mandatory reporting laws require healthcare providers to report
suspected elder abuse.
7. A client is prescribed digoxin. Which finding indicates digoxin toxicity?
A. Hypertension
B. Nausea and visual halos
C. Increased appetite
D. Hyperkalemia
, Digoxin toxicity presents with GI symptoms and visual disturbances such as
seeing halos.
8. A nurse receives an order for "morphine sulfate 2 mg IV every 4 hours
PRN pain." What is the priority action?
A. Clarify if the dosage is for severe or moderate pain
B. Administer medication as ordered
C. Check the client’s BP only
D. Ask the UAP to assess the pain
PRN medications require a clear indication; clarification is needed to
ensure safe administration.
9. A client develops urticaria and wheezing after receiving a medication.
What is the nurse’s priority action?
A. Administer epinephrine
B. Monitor for fever
C. Check for cyanosis
D. Notify pharmacy
Epinephrine is the first-line treatment for anaphylaxis, which includes
wheezing and hives.
EXAM 2 QUESTIONS AND CORRECT
ANSWERS (VERIFIED ANSWERS) PLUS
RATIONALES 2025
1. A nurse is caring for a client with a serum potassium level of 2.9 mEq/L.
Which intervention is most appropriate?
A. Administer potassium chloride IV push
B. Administer potassium chloride IV diluted in NS
C. Restrict potassium intake
D. Monitor for hyperkalemia symptoms
IV potassium must be diluted and administered slowly to prevent cardiac
complications. A serum potassium of 2.9 mEq/L indicates hypokalemia.
2. Which task can the RN safely delegate to an unlicensed assistive
personnel (UAP)?
A. Teaching incentive spirometry
,B. Performing initial pain assessment
C. Interpreting blood glucose levels
D. Ambulating a stable post-op client
UAPs can assist with ambulation of stable patients. Teaching and
assessment require RN expertise.
3. A client with COPD is receiving oxygen therapy. Which oxygen delivery
system is most appropriate?
A. Non-rebreather mask at 15 L/min
B. Simple face mask at 10 L/min
C. Nasal cannula at 2 L/min
D. Venturi mask at 60%
Clients with COPD retain CO₂ and should receive low-flow oxygen to
prevent respiratory depression.
4. What is the priority nursing action for a client experiencing chest pain
unrelieved by rest?
A. Administer antacids
B. Administer prescribed nitroglycerin
C. Call the rapid response team
D. Monitor pain for 30 minutes
Nitroglycerin is the first-line treatment for angina. It dilates coronary
arteries and relieves pain.
,5. Which lab value indicates effective warfarin therapy?
A. INR 1.0
B. INR 2.5
C. INR 4.5
D. INR 0.8
An INR of 2.0 to 3.0 indicates therapeutic warfarin levels for most
indications.
6. A nurse suspects elder abuse. What is the most appropriate action?
A. Discuss suspicions with family
B. Report findings to Adult Protective Services
C. Document concern in hidden notes
D. Wait for more evidence
Mandatory reporting laws require healthcare providers to report
suspected elder abuse.
7. A client is prescribed digoxin. Which finding indicates digoxin toxicity?
A. Hypertension
B. Nausea and visual halos
C. Increased appetite
D. Hyperkalemia
, Digoxin toxicity presents with GI symptoms and visual disturbances such as
seeing halos.
8. A nurse receives an order for "morphine sulfate 2 mg IV every 4 hours
PRN pain." What is the priority action?
A. Clarify if the dosage is for severe or moderate pain
B. Administer medication as ordered
C. Check the client’s BP only
D. Ask the UAP to assess the pain
PRN medications require a clear indication; clarification is needed to
ensure safe administration.
9. A client develops urticaria and wheezing after receiving a medication.
What is the nurse’s priority action?
A. Administer epinephrine
B. Monitor for fever
C. Check for cyanosis
D. Notify pharmacy
Epinephrine is the first-line treatment for anaphylaxis, which includes
wheezing and hives.
