HESI Compass exit exam

Question 1: View When assessing a client who had a transurethral resection of the prostate (TURP) one day ago, the nurse observes that his scrotum and penis are edematous. Which intervention(s) should the nurse implement? Select all that apply.

A. Put a pillow under the buttocks. B. Apply a cold pack to the scrotal and penile areas. C. Obtain a specimen for urinalysis. D. Remove the indwelling urinary catheter. E. Notify the healthcare provider immediately.

Explanation

Choice A reason: Elevating the buttocks with a pillow is not specifically indicated in the scenario provided. While it might assist in other situations to reduce swelling by using gravity, it isn't a standard intervention for the described situation post-TURP.

Choice B reason: Applying a cold pack to the scrotal and penile areas can help reduce the swelling and discomfort associated with edema. Cold therapy is effective in constricting blood vessels and reducing inflammation, making it an appropriate immediate intervention.

Choice C reason: While obtaining a urinalysis might provide information on the presence of infection or other abnormalities, it does not directly address the immediate issue of the observed edema. Therefore, it is not a primary intervention in this scenario.

Choice D reason: Removing the indwelling urinary catheter without specific orders can lead to complications and is not advised as an initial intervention. The catheter serves a critical purpose post-surgery and should be handled according to protocol or provider direction.

Choice E reason: Notifying the healthcare provider immediately is crucial when unexpected postoperative complications such as edema occur. Prompt communication allows for timely medical intervention and ensures that the patient receives the necessary care.

Question 2: View During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

A. History of suicide attempts. B. Family history of schizophrenia. C. Undiagnosed social anxiety symptoms (SAD). D. Feelings of disorientation.

Explanation

Choice A reason: A history of suicide attempts is crucial information when planning the care of a client using heroin because there is a high risk of further suicide attempts, especially in individuals with substance use disorders. The nurse must prioritize mental health safety and implement measures to monitor and support the client's psychological well-being to prevent any potential self-harm.

Choice B reason: While family history of schizophrenia is important, it is not immediately crucial to the plan of care for a client currently using heroin. This information is more relevant for long-term monitoring and psychiatric evaluation rather than immediate care planning.

Choice C reason: Undiagnosed social anxiety disorder (SAD) may contribute to substance use; however, it is not the most urgent concern in this scenario. The focus should be on immediate safety and stabilization, particularly addressing the high risk of suicide.

Choice D reason: Feelings of disorientation are significant but could be a result of heroin use. While important to assess, they are secondary to the immediate concern of preventing self-harm in a client with a history of suicide attempts.

Question 3: View

The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

A. Severe motor dysfunction determines the extent of successful habilitation. B. Continued development of the brain lesion determines the child's outcome. C. Brain damage with CP is not progressive but does have a variable course. D. CP is one of the most common permanent physical disabilities in children.

Explanation

Choice A reason: Severe motor dysfunction does influence the extent of successful habilitation, but it does not fully answer the mother’s concern regarding the progression of CP. The focus should be on reassuring the mother about the non-progressive nature of CP.

Choice B reason: The development of the brain lesion is already established in CP and does not continue to develop; thus, it does not determine the child's future outcome. The brain lesion's presence from birth does not change over time.

Choice C reason: Brain damage associated with CP is non-progressive, meaning it does not worsen over time. However, the symptoms and functional impairments can vary and fluctuate, which might make it seem as though the condition is changing.

Choice D reason: While it’s true that CP is one of the most common permanent physical disabilities in children, it doesn’t provide specific information about the progression of the disease. The mother needs to understand that the brain damage itself is not progressive.

Question 4: View A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

A. Mix the next dose with food. B. Administer a half dose now. C. Withhold this dose. D. Give another dose.

Explanation

Choice A reason: Mixing the next dose with food is not recommended because digoxin is better absorbed on an empty stomach and food may interfere with its absorption. Additionally, this option does not address the immediate issue of the infant vomiting after the dose.

Choice B reason: Administering a half dose is not appropriate because it may lead to incorrect dosing and potential under-treatment or toxicity. The exact dose must be given according to medical guidelines.

Choice C reason: Withholding the dose is the best course of action. If an infant vomits after receiving a dose of medication, particularly a critical one like digoxin, it is essential to wait until the next scheduled dose to avoid potential overdose or toxic effects.

Choice D reason: Giving another dose is not recommended because it could lead to toxicity, especially considering the infant might have partially absorbed the initial dose before vomiting.

Question 5: View One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in this client's plan of care?

A. Explain the need for skin exposure to sunlight without sunscreen. B. Teach the need for dietary and supplemental vitamin D. C. Instruct the client in the use of muscle strengthening exercises. D. Encourage progressive active range of motion.

Explanation

Choice A reason: Explaining the need for skin exposure to sunlight without sunscreen is not advisable because it can increase the risk of further skin damage or skin cancer, especially in a client with a history of severe burns. Sunscreen should be used to protect the skin from harmful UV rays.

Choice B reason: Teaching the need for dietary and supplemental vitamin D is important because clients with extensive burns often have impaired vitamin D synthesis due to reduced exposure to sunlight and possible nutritional deficiencies. Vitamin D is essential for bone health and muscle function.

Choice C reason: Instructing the client in the use of muscle strengthening exercises is beneficial for overall health, but it does not directly address the specific issue of bone pain and muscle weakness related to potential vitamin D deficiency.

Choice D reason: Encouraging progressive active range of motion is important for maintaining joint flexibility and function, but it does not directly address the underlying cause of bone pain and muscle weakness in this scenario.

Question 6: View

A client presents to the clinic with fatigue, poor appetite, general malaise, and vague joint pain that improves mid-morning. The client has been taking over-the-counter ibuprofen for several months. The healthcare provider makes an initial diagnosis of rheumatoid arthritis (RA).

Which laboratory test(s) should the nurse report to the healthcare provider? Select all that apply.

A. Sedimentation rate B. Anti-cyclic citrullinated peptide (anti-CCP) antibodies C. D-Dimer D. C-reactive protein E. White blood cell count

Explanation

Choice A reason: The sedimentation rate (ESR) is a common test used to detect inflammation associated with conditions such as rheumatoid arthritis. An elevated ESR indicates the presence of inflammation in the body.

Choice B reason: Anti-cyclic citrullinated peptide (anti-CCP) antibodies are highly specific for rheumatoid arthritis and are useful in confirming the diagnosis. The presence of these antibodies can help distinguish RA from other inflammatory conditions.

Choice C reason: D-Dimer is primarily used to rule out thrombotic conditions such as deep vein thrombosis and pulmonary embolism. It is not specifically related to the diagnosis or management of rheumatoid arthritis.

Choice D reason: C-reactive protein (CRP) is another marker of inflammation that is often elevated in rheumatoid arthritis. It provides information about the level of inflammation and can be used to monitor disease activity and response to treatment.

Choice E reason: While a white blood cell count can provide general information about infection or inflammation, it is not specific to rheumatoid arthritis and is not as useful as the other tests mentioned for diagnosing or managing RA.

Question 7: View An older adult client who cares for her husband at home has just learned that she needs to have knee replacement surgery. She tells the nurse she is concerned about her inability to provide care to her husband while she recovers from surgery and attends physical therapy. She has a friend who can drive her to and from her appointments once she is discharged, but cannot provide the care her husband needs. How should the nurse respond to the client?

A. Recommend that the client's family return to the area to help provide assistance. B. Advise to have a case management evaluation of the client's home environment. C. Suggest contacting social services to help find a respite care facility for her husband. D. Tell her to consider hiring a private nurse during the postoperative convalescence.

Explanation

Choice A reason: Recommending that the client's family return to the area to help provide assistance is not always feasible and may place undue stress on the family. It is also not a sustainable long-term solution.

Choice B reason: Advising a case management evaluation of the client's home environment is the best response as it allows for a comprehensive assessment of the client's needs and resources. The case manager can help coordinate care, arrange for necessary services, and provide support for both the client and her husband.

Choice C reason: Suggesting contacting social services to help find a respite care facility for her husband is a reasonable option, but it may not be the most immediate or suitable solution for the client’s concerns. This option should be considered as part of the overall case management plan.

Choice D reason: Telling her to consider hiring a private nurse during the postoperative convalescence may be helpful, but it can be costly and may not be necessary if other support systems are in place. It should be discussed as part of the case management evaluation.

Question 8: View In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

A. Nausea and headache. B. Increased fatigue. C. Yellow-tinged sputum. D. Watery diarrhea.

Explanation

Choice A reason: Nausea and headache are common side effects of many medications, including linezolid, but they are not the most critical findings that need immediate reporting to the healthcare provider.

Choice B reason: Increased fatigue is a concerning symptom but may be related to the underlying infection or other factors. It is important to monitor but is not the most urgent finding in this context.

Choice C reason: Yellow-tinged sputum may indicate an ongoing infection, but it is not uncommon in cases of pneumonia. It should be monitored but does not require immediate reporting unless there are other concerning symptoms.

Choice D reason: Watery diarrhea is the most important finding to report because linezolid can cause Clostridioides difficile-associated diarrhea (CDAD), a potentially serious condition. Early detection and treatment are crucial to prevent complications.

Question 9: View A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

A. Monitor daily sodium intake. B. Measure ankle circumference. C. Obtain serum creatinine levels daily. D. Ensure client takes a diuretic every morning.

Explanation

Choice A reason: Monitoring daily sodium intake is crucial because SIADH often leads to hyponatremia (low sodium levels). Keeping track of sodium intake helps manage and prevent complications associated with sodium imbalances, such as seizures or confusion.

Choice B reason: Measuring ankle circumference can help assess fluid retention, but it is not the first intervention. It is more important to address the underlying issue of sodium imbalance.

Choice C reason: Obtaining serum creatinine levels daily can provide information about kidney function but does not directly address the immediate concern of sodium and fluid balance in SIADH.

Choice D reason: Ensuring the client takes a diuretic every morning may be part of the treatment plan, but it is more important to first monitor and manage sodium levels to ensure safe and effective use of diuretics.

Question 10: View While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

A. Sodium intake with meals and snacks affects the blood pressure. B. Hypotension leading to sudden shock can develop at any time. C. Elevated blood pressure must be anticipated and identified quickly. D. Blood pressure fluctuations mean that the condition has become chronic.

Explanation

Choice A reason: While sodium intake can affect blood pressure, this response does not address the importance of frequent blood pressure monitoring in the context of acute glomerulonephritis.

Choice B reason: Hypotension leading to sudden shock is not a common complication of acute glomerulonephritis; instead, hypertension is more likely due to fluid retention and kidney impairment.

Choice C reason: Elevated blood pressure is a significant concern in acute glomerulonephritis due to fluid retention and decreased kidney function. Early identification and management of hypertension are crucial to prevent complications such as seizures or heart failure.

Choice D reason: Blood pressure fluctuations do not necessarily indicate that the condition has become chronic. Frequent monitoring is necessary to manage acute symptoms and prevent complications.