HESI BSN395 Compass Exit Exam
Access The Exact Questions for HESI BSN395 Compass Exit Exam
💯 100% Pass Rate guaranteed
🗓️ Unlock for 1 Month
Rated 4.8/5 from over 1000+ reviews
- Unlimited Exact Practice Test Questions
- Trusted By 200 Million Students and Professors
What’s Included:
- Unlock Actual Exam Questions and Answers for HESI BSN395 Compass Exit Exam on monthly basis
- Well-structured questions covering all topics, accompanied by organized images.
- Learn from mistakes with detailed answer explanations.
- Easy To understand explanations for all students.
Ace Your Test with HESI BSN395 Compass Exit Exam Actual Questions and Solutions - Full Set
Free HESI BSN395 Compass Exit Exam Questions
-
Mechanical soft.
-
Pureed diet.
-
Full liquid.
-
Clear liquid.
Explanation
Following bowel resection surgery, the gastrointestinal tract needs time to recover from the surgical trauma, anesthesia, and manipulation before it can tolerate solid or complex foods. A clear liquid diet is the standard initial diet prescribed immediately after bowel surgery because it provides hydration and minimal gut stimulation while allowing the nurse and surgical team to assess the return of bowel function, the integrity of surgical anastomoses, and the client's tolerance of oral intake. Clear liquids require minimal digestive processing, leave no residue in the bowel, and reduce the risk of complications such as anastomotic leak, bowel obstruction, and ileus in the immediate postoperative period. As bowel function returns and the client tolerates clear liquids without complications, the diet is progressively advanced.
Why the other options are incorrect:
A mechanical soft diet consists of soft, easily chewed foods that require minimal mechanical breakdown. While this diet is appropriate for clients with chewing difficulties or oral problems, it is not appropriate immediately following bowel resection surgery because it still contains solid food particles that place demands on the healing gastrointestinal tract.
A pureed diet consists of foods blended to a smooth consistency and is used for clients with swallowing difficulties or severe dysphagia. It is not the appropriate initial post-surgical diet following bowel resection because pureed foods still require digestion and bowel motility, which may not be adequately restored in the immediate postoperative period.
A full liquid diet includes all clear liquids plus milk, cream soups, puddings, and other liquid dairy products. While this diet represents the next progression after clear liquids, it is not the initial diet prescribed immediately after bowel resection surgery. The progression from clear liquids to full liquids to soft foods to regular diet occurs gradually as the client demonstrates tolerance and bowel function returns.
-
Administer prescribed PRN sleep medications.
-
Encourage use of prescribed analgesic perineal sprays.
-
Administer prescribed stool softener.
-
Encourage breastfeeding to promote uterine involution.
Explanation
Correct Answer: (C) Administer prescribed stool softener.
A fourth degree laceration extends through the perineal skin, vaginal mucosa, perineal muscles, anal sphincter, and through the rectal mucosa. This is the most severe type of obstetric laceration. The highest priority intervention is administering a stool softener to prevent straining during bowel movements, which could cause extreme pain, disrupt the surgical repair, and lead to serious complications such as wound dehiscence or damage to the repaired anal sphincter. Preventing trauma to the repair site through stool softening is the most critical intervention for healing and complication prevention.
Why the other options are incorrect:
A. Administer prescribed PRN sleep medications. While rest and sleep are important for postpartum recovery, sleep medication is not a priority intervention for a client with a fourth degree laceration. Pain management and wound protection take precedence.
B. Encourage use of prescribed analgesic perineal sprays. While analgesic perineal sprays provide comfort and pain relief, they do not address the highest priority concern of preventing mechanical trauma to the repair site from straining during bowel movements. Pain management is secondary to protecting the wound integrity.
D. Encourage breastfeeding to promote uterine involution. While breastfeeding is beneficial for uterine involution and is encouraged postpartum, it is not the highest priority intervention specifically related to the management and protection of a fourth degree laceration repair.
-
Explain that the client will start to lose consciousness and the body systems will slow down.
-
Gather information regarding how long it will take for the children to arrive.
-
Offer to discuss the client's health status with each of the adult children.
-
Reassure the spouse that the healthcare provider (HCP) will notify when to call the children.
Explanation
Correct Answer: (A) Explain that the client will start to lose consciousness and the body systems will slow down.
This response provides the spouse with accurate, compassionate, and clinically appropriate information about the signs of imminent death. Educating the family about what to expect, including decreased level of consciousness, slowing of body systems, changes in breathing patterns, and reduced circulation, empowers them to recognize when death is approaching so they can ensure their children are present. This is the most therapeutic and informative response that directly addresses the spouse's question.
Why the other options are incorrect:
B. Gather information regarding how long it will take for the children to arrive. While this information may eventually be relevant for planning, it does not address the spouse's immediate question about how to recognize when death is imminent and does not provide the education needed to make an informed decision about calling the children.
C. Offer to discuss the client's health status with each of the adult children. While family communication is important, this response deflects from the spouse's direct question and delays the education the spouse needs right now to recognize the signs of imminent death and act accordingly.
D. Reassure the spouse that the healthcare provider will notify when to call the children. This response inappropriately transfers responsibility to the HCP and gives the spouse a false sense of security. The nurse has both the knowledge and the responsibility to educate the family about end-of-life signs rather than deferring this critical communication to another provider.
Nurses' Notes:
1020: Client arrives at the emergency department (ED) and is placed in an exam room. History and assessment, including vital signs, are completed. Reports tightness in her lower left leg and a 1 day history of not feeling well with generalized muscle aches. An assessment of the left lower leg finds it to be red, warm, and swollen starting at the ankle and outer aspect of the foot. A small scab is noted above the lateral ankle. Client reports having a small cut when shaving her legs earlier in the week. Bilateral toes are cool to touch. The left calf temperature is warmer than the right but cooler than the upper extremities.
1030: A capillary blood glucose level is obtained. IV access is established in the left antecubital, and laboratory specimens are collected.
Laboratory Results:
Glucose result is 252 mg/dL (13.9 mmol/L), with a reference range of 74 to 106 mg/dL (4.1 to 5.9 mmol/L), indicating a critically elevated blood glucose level.
Flow Sheet:
1000 — Vital Signs: Temperature 100.5°F (38°C) orally, heart rate 88 beats/minute, respiratory rate 20 breaths/minute, blood pressure 122/72 mm Hg, oxygen saturation 98% on room air, pain 2 on a 0 to 10 scale with bilateral lower legs described from neuropathy and tightness in left calf, weight 284 lb (129.1 kg), height 5 ft 2 in (157.48 cm), body circumference right calf 16.5 in (41.9 cm) and left calf 17.25 in (43.8 cm), capillary refill greater than 3 seconds bilateral lower extremities.
Orders:
1030: Obtain capillary blood glucose level, establish peripheral IV access, obtain two sets of peripheral blood cultures, obtain serum white blood count and lactate.
Highlight the findings that require the nurse's attention. Select all that apply.
I. Pain 2 on a 0 to 10 pain scale, bilateral lower legs described from neuropathy
J. Body circumference: Right calf 16.5 in (41.9 cm); left calf 17.25 in (43.8 cm)
- Heart rate 88 beats/minute
- Blood pressure 122/72 mm Hg
- Temperature 100.5°F (38°C)
- Reports of pain with ambulation
- Respirations 20 breaths/minute
- Left lower leg with erythema, warm, and swollen
- Blood glucose 252 mg/dL (13.9 mmol/L)
- Capillary refill greater than 3 seconds bilateral lower extremities
- I. Pain 2 on a 0 to 10 pain scale, bilateral lower legs described from neuropathy
- J. Body circumference: Right calf 16.5 in (41.9 cm); left calf 17.25 in (43.8 cm)
Explanation
Correct Answers: (C) Temperature 100.5°F (38°C), (D) Reports of pain with ambulation, (F) Left lower leg with erythema, warm, and swollen, (G) Blood glucose 252 mg/dL (13.9 mmol/L), (H) Capillary refill greater than 3 seconds bilateral lower extremities, and (J) Body circumference: Right calf 16.5 in (41.9 cm); left calf 17.25 in (43.8 cm)
These findings collectively point toward a serious infectious and vascular emergency in a highly complex client with multiple comorbidities. The low-grade fever of 100.5°F is a systemic sign of infection, consistent with cellulitis or a deeper soft tissue infection entering the bloodstream, which is especially dangerous in a diabetic client with peripheral vascular disease and stage 3a kidney disease. Pain with ambulation is a significant finding because it indicates that the inflammatory or infectious process is severe enough to impair the client's functional mobility, and in the context of peripheral vascular disease, it raises concern for ischemic pain as well. The left lower leg being red, warm, and swollen starting at the ankle with a recent skin break from shaving is the hallmark presentation of cellulitis, a bacterial skin infection that can rapidly progress to sepsis in an immunocompromised diabetic client. The blood glucose of 252 mg/dL is critically elevated well above the reference range of 74 to 106 mg/dL, indicating poorly controlled diabetes that impairs immune function and wound healing, significantly worsening the client's ability to fight the infection. Capillary refill greater than 3 seconds bilaterally in the lower extremities indicates impaired peripheral perfusion, which in this client with peripheral vascular disease and heart failure suggests compromised circulation that reduces the delivery of immune cells and antibiotics to the infected area. The asymmetry in calf circumference, with the left calf measuring 17.25 in compared to the right calf at 16.5 in, is a clinically significant finding because unilateral calf swelling raises concern for deep vein thrombosis (DVT) in addition to cellulitis, and both conditions can coexist and must be differentiated urgently.
Why Other Options Do Not Require Immediate Attention:
Heart rate of 88 beats/minute is within the normal range of 60 to 100 beats/minute and does not represent an abnormal or urgent finding in isolation for this client, though it should continue to be monitored given the infection risk.
Blood pressure of 122/72 mm Hg is within a normal and acceptable range, particularly for a client with hypertension on medication. It does not represent an urgent concern at this time and does not require immediate nursing intervention beyond continued monitoring.
Respirations of 20 breaths/minute fall at the upper limit of the normal adult range of 12 to 20 breaths/minute and are not an immediately alarming finding in this context. While it warrants monitoring, it does not require priority nursing attention compared to the other abnormal findings.
Pain rated 2 out of 10 bilaterally described as neuropathic is a chronic baseline finding related to the client's known diabetic neuropathy and peripheral vascular disease. It does not represent a new or acute change requiring immediate intervention, unlike the pain with ambulation which is a new and functionally significant symptom.
-
Observe body language and movement.
-
Identify effective pain relief measures.
-
Provide a numeric pain scale.
-
Ask the client to describe the pain.
Explanation
Correct Answer: (D) Ask the client to describe the pain
The quality of pain refers to the character or nature of the pain, such as whether it is sharp, dull, burning, stabbing, throbbing, or aching. The only way to accurately assess the quality of pain is to ask the client to describe it in their own words, as quality is a subjective experience that cannot be determined through observation alone. This approach aligns with the principle that the client is the expert on their own pain experience, and verbal description provides the most direct and accurate information about pain quality.
Why Other Options Are Incorrect:
Observing body language and movement provides information about the behavioral response to pain and can help assess pain intensity in clients who cannot verbally communicate, but it does not directly assess the quality or character of the pain.
Identifying effective pain relief measures addresses the management of pain rather than the assessment of its quality. While important for the overall pain management plan, it does not answer the question of what the pain feels like to the client.
Providing a numeric pain scale assesses the intensity or severity of pain on a quantitative scale from 0 to 10, not the quality or character of the pain. Intensity and quality are two different dimensions of pain assessment that require different approaches.
Nurses' Notes:
2345: The healthcare provider (HCP) assesses the client. New prescriptions are received. Did a nasal swab and applied a urine collection bag. Observed the mother trying to calm the infant, who has increased fussiness. Integumentary: Intact, pale, and hot to the touch. Poor skin turgor noted.
Day 2 — 0010: The child is fussy, but able to place on a nasal cannula at 1 liter/minute. The oxygen saturation level increases with the application of oxygen; although, internal coastal and suprasternal reactions are visibly evident. Child is taken for a chest x-ray.
Day 2 — 0020: Infant is back in the room and shows obvious signs of discomfort. Performed the face, legs, activity, cry, consolability (FLACC) pain assessment. The mother reports she changed the infant's diaper on return and placed it on the counter. She voices concern as the child is not drinking formula or urinating much. Findings reported to the healthcare provider. New prescriptions are received.
Laboratory Results:
Day 2 — 0020 — Respiratory Syncytial Virus (RSV) Rapid Test: The rapid antigen respiratory syncytial virus test result is Positive (Reference Range: Negative).
Flow Sheet:
2330 — Vital Signs: Temperature 101.2°F (38.4°C), heart rate 154 beats/minute, respiratory rate 64 breaths/minute, blood pressure 76/48 mm Hg, oxygen saturation 92% on room air, weight 13 pounds 2 ounces (5.9 kg), height 25.2 inches (64 cm).
Day 2 — 0000 — Vital Signs: Temperature 101.2°F (38.4°C), heart rate 156 beats/minute, respiratory rate 66 breaths/minute, oxygen saturation 87% on room air, FLACC scale rated 7 on a 0 to 10 scale.
Day 2 — 0020 — Vital Signs: Oxygen saturation 93% on 1-liter oxygen by nasal cannula, output 50 mL urine, strong smelling.
Orders:
2345: STAT rapid antigen respiratory syncytial virus (RSV) test, STAT chest x-ray, urine collection bag.
Day 2 — 0020: Complete blood count (CBC), insert peripheral IV line, infuse bolus of lactated Ringer's 20 mL/kg over 20 minutes via intravenous (IV) line, acetaminophen 10 mg/kg by mouth for pain or for temperature above 100.4°F (38°C).
Question: The child returns from the chest x-ray. Given a diagnosis of respiratory syncytial virus (RSV) with bronchiolitis, the nurse reviews the prescriptions to decide what to prioritize.
Choose from the most likely options for the information missing from the statement(s) by selecting from the lists of options provided.
The nurse prioritizes the ___ first due to ___, which is supported by the symptom of ___.
Dropdown 1 options: Integumentary system, Genitourinary system, Gastrointestinal system, Respiratory system
Dropdown 2 options: Ineffective breathing, Bacterial infection, Significant dehydration
Dropdown 3 options: Low urine output, Elevated temperature, Poor skin turgor
- Integumentary system
- Genitourinary system
- Gastrointestinal system
- Respiratory system
- Ineffective breathing
- Bacterial infection
- Significant dehydration
- Low urine output
- Elevated temperature
- Poor skin turgor
Explanation
The nurse prioritizes the Respiratory system first due to Ineffective breathing, which is supported by the symptom of intercostal and suprasternal retractions
In a child diagnosed with RSV bronchiolitis, the respiratory system is the highest priority because airway inflammation and mucus production directly compromise breathing effectiveness. The child's SpO₂ dropped to 87% on room air at 0000, only improving to 93% with supplemental oxygen at 1 L/minute via nasal cannula. Visible intercostal and suprasternal retractions documented in the nurse's notes are classic signs of increased work of breathing and confirm ineffective breathing as the primary concern. Per the ABCs of nursing priority (Airway, Breathing, Circulation), respiratory compromise always takes precedence.
Why the other options are incorrect:
- Integumentary system — Poor skin turgor is a sign of dehydration and is clinically significant, but it does not represent an immediately life-threatening emergency compared to respiratory failure with an SpO₂ of 87%.
- Genitourinary system — Low urine output (50 mL, strong smelling) and only two minimally wet diapers indicate dehydration, which is addressed with the IV fluid bolus order, but this is secondary to the respiratory emergency.
- Gastrointestinal system — Decreased formula intake contributes to dehydration but is not the immediate life-threatening priority.
- Bacterial infection — RSV is a viral illness and there is no documented evidence of bacterial superinfection at this time, making this an incorrect rationale for prioritization.
- Significant dehydration — While dehydration is present and being treated with IV fluids, it is not more immediately life-threatening than severe respiratory distress with dangerously low oxygen saturation.
- Elevated temperature — Fever at 101.2°F is present and addressed with acetaminophen in the orders, but it is a secondary concern compared to respiratory compromise.
- Low urine output — This supports the dehydration and genitourinary concern, not the respiratory priority, and is therefore not the correct supporting symptom for why the respiratory system is prioritized.
Nurses' Notes:
POD 2 (0845): Client tolerated the surgical procedure well and has been stable since surgery.
POD 3 (0700): Is postoperative below-the-knee amputation right leg day 3. He is sitting up with his left leg and right leg residual limb hanging off the bed. There is patient-controlled analgesia (PCA) of morphine on demand in the left hand area; there is no redness at the site with 0.9% sodium chloride infusing at 50 mL/hr.
Assessment: General: Alert, oriented to person, place, time, and situation. Eyes: Pupils equal, round, reactive to light accommodation (PERRLA). Lungs: Lungs clear all lobes. Heart: Telemetry monitor displaying normal sinus rhythm (NSR). Abdomen: Abdomen soft, bowel sounds in all 4 quadrants. Denies pain with urination and describes urine as light yellow. Right leg: Right leg incision is open to air, skin to the area is cool to touch, and edema noted along the incision. Sutures intact, no redness noted, popliteal pulses strong bilaterally and wound drain with approximately 100 mL red drainage present right leg. Reports pain is a 2 on a 0 to 10 scale, right residual limb area. Left leg: 2+ pedal pulse, loss of hair on the lower leg, skin is dry, scaly, cool to touch, thickened toenails noted, and capillary refill is greater than 4 seconds.
Flow Sheet POD 3 (0700): Temperature: 98.2°F (36.7°C) orally Heart rate: 88 beats/minute normal sinus rhythm (NSR) Respirations: 20 breaths/minute Blood pressure: 126/84 mm Hg Oxygen saturation: 95% on room air Pain: 2 on a 0 to 10 scale, right leg incisional area
Orders (Admit 0845): Leave incision open to air Clean residual limb twice daily with 4 by 4's moistened with 0.9% sodium chloride and pat dry Right residual limb to lie flat in bed Prone position 2 times daily for 30 minutes Atenolol 50 mg PO twice daily Lovastatin 20 mg PO with evening meal Enoxaparin 40 mg subcutaneous every morning Penicillin 500 mg IV piggyback (IVPB) every 6 hours Incentive spirometer Out of bed with assistance by physical therapy (PT) twice daily Laboratory: complete blood count (CBC) with differential, basic metabolic panel, partial prothrombin time (PTT) Low sodium diet Infuse 0.9% sodium chloride IV at 50 mL/hour Patient-controlled analgesia (PCA) settings
For each client activity below, indicate whether it shows Positive or Negative health promotion postoperative amputation due to extensive peripheral vascular disease (PVD).
For each activity, identify whether it represents Positive or Negative health promotion behavior.
-
Executes pull ups on trapeze bar
-
Avoids looking at residual limb
-
Asks questions about self care
-
Turns side to side
-
Requests nurse to perform wound care
-
Inquires about blood pressure
Explanation
Correct Answer:
(A) Executes pull ups on trapeze bar — Positive
Using the trapeze bar to perform pull ups builds upper body strength, promotes independence with repositioning, and reduces the risk of skin breakdown and DVT by facilitating movement. This is a positive indicator of active participation in recovery and demonstrates the client's motivation to regain strength and independence following amputation.
(B) Avoids looking at residual limb — Negative
Avoiding looking at the residual limb suggests the client is having difficulty accepting the change in body image. Acceptance and acknowledgment of the residual limb are important steps in the psychological adjustment process and are necessary for the client to learn proper stump care and prosthetic management. This behavior indicates a need for therapeutic coping interventions and body image support from the nurse.
(C) Asks questions about self care — Positive
Asking questions about self care demonstrates engagement, motivation, and readiness to learn, which are all positive indicators of health promotion and successful rehabilitation following amputation. This behavior reflects the client's desire to take an active role in their own recovery and transition toward independence.
(D) Turns side to side — Positive
Repositioning by turning side to side prevents pressure injuries, promotes circulation, and reduces the risk of complications from immobility including atelectasis and DVT. This is a positive health promotion behavior that demonstrates the client's active participation in preventing postoperative complications.
(E) Requests nurse to perform wound care — Negative
While it is appropriate for the nurse to perform wound care initially, a client who consistently requests the nurse to perform all wound care rather than learning to participate in self-care demonstrates a lack of independence and readiness for discharge. Self-care participation is a key rehabilitation goal for amputation clients, and the nurse should use this as an opportunity to begin teaching the client wound care techniques to promote self-sufficiency.
(F) Inquires about blood pressure — Positive
Given the client's history of hypertension and PVD, inquiring about blood pressure demonstrates health awareness and engagement in managing chronic conditions that directly affect vascular health and postoperative recovery. This behavior shows the client understands the importance of blood pressure management in relation to their vascular disease and overall health outcomes.
0900: A 72-year-old male client presents to a urology clinic from home for scheduled prostate biopsy. He has experienced progressively worsening urinary hesitancy, straining to void, and nocturia occurring 3 to 4 times nightly for the past 6 months. He reports a sensation of incomplete bladder emptying and decreased urine stream. He denies fever, dysuria, or flank pain. He reports intermittent suprapubic pressure.
Past medical history: hypertension, hyperlipidemia. Home medications: Atorvastatin 20 mg PO nightly, lisinopril 10 mg PO daily. Allergies: no known drug allergies.
Nurses' Notes:
1015: The client is in the recovery area following a transrectal ultrasound-guided prostate biopsy. He reports mild rectal discomfort and continued difficulty initiating urination. Urine output since the procedure has been minimal. No active rectal bleeding observed.
Laboratory Results:
0830 — Complete Blood Count: White blood cells 7,200/mm³ (7.2 x 10⁹/L), reference range 5,000 to 10,000/mm³ (5 to 10 x 10⁹/L). Red blood cells 4.8 x 10⁶/µL (4.8 x 10¹²/L), reference range 4.7 to 6.1 x 10⁶/µL (4.7 to 6.1 x 10¹²/L). Hemoglobin 14.2 g/dL (142 g/L), reference range 14 to 18 g/dL (120 to 160 g/L). Hematocrit 43% (0.43 volume fraction), reference range 42% to 52% (0.42 to 0.52 volume fraction). Platelet count 210,000/mm³ (210 x 10⁹/L), reference range 150,000 to 400,000/mm³ (150 to 400 x 10⁹/L).
Prostate-specific antigen (PSA): 12.6 ng/mL (12.6 µg/L), reference range 0 to 4 ng/mL (0 to 4 µg/L).
Flow Sheet:
1030 — Vital Signs: Temperature 98.4°F (36.9°C), heart rate 82 beats/minute, respirations 16 breaths/minute, blood pressure 136/80 mm Hg, oxygen saturation on room air 98%, pain 3 on a 0 to 10 scale described as rectal discomfort.
Orders:
0945: Bladder scan if unable to void within 4 hours, discharge home after observation period, observe for hematuria for 2 hours post-procedure.
Imaging Studies:
0915: Transrectal ultrasound: Hypoechoic lesion identified in the peripheral zone of the prostate. Biopsy obtained, pathology results pending.
Question: The nurse is reviewing the client's findings in the recovery area following the transrectal ultrasound-guided prostate biopsy. Based on the client's history, laboratory results, and post-procedure assessment, which findings require priority follow-up by the nurse? Select all that apply.
- PSA level of 12.6 ng/mL.
- Minimal urine output since the procedure.
- Pain rated 3 on a 0 to 10 scale described as rectal discomfort.
- Blood pressure of 136/80 mm Hg.
- Hypoechoic lesion identified in the peripheral zone of the prostate.
- Continued difficulty initiating urination post-procedure.
- White blood cell count of 7,200/mm³.
Explanation
Correct Answers: (A) PSA level of 12.6 ng/mL, (B) Minimal urine output since the procedure, (E) Hypoechoic lesion identified in the peripheral zone of the prostate, and (F) Continued difficulty initiating urination post-procedure
The PSA level of 12.6 ng/mL is critically elevated, more than three times the upper limit of the normal reference range of 0 to 4 ng/mL. A significantly elevated PSA combined with a hypoechoic lesion in the peripheral zone of the prostate on transrectal ultrasound are both highly suspicious findings for prostate cancer. While the pathology results are still pending, these findings together indicate a strong likelihood of malignancy and require priority follow-up, provider notification, and patient education once results are available.
Minimal urine output since the procedure is a priority concern because the client already had pre-existing urinary hesitancy and incomplete bladder emptying before the biopsy, and post-procedure swelling and inflammation of the prostate can worsen urinary obstruction significantly. The order for a bladder scan if the client is unable to void within 4 hours directly addresses this concern, confirming that the clinical team recognizes urinary retention as a high-priority post-procedure complication that must be monitored and managed promptly to prevent bladder distension and injury.
The hypoechoic lesion in the peripheral zone of the prostate is a significant imaging finding because the peripheral zone is the most common site for prostate adenocarcinoma, and a hypoechoic lesion in this location combined with the markedly elevated PSA strongly raises the clinical suspicion for malignancy. This finding requires priority follow-up once pathology results are available and necessitates clear and sensitive communication with the client and his family.
Continued difficulty initiating urination post-procedure is a priority follow-up finding because it indicates that the urinary obstruction that was present pre-operatively has not resolved and may be worsening due to post-biopsy prostate edema and inflammation. In conjunction with minimal urine output, this finding increases the risk of acute urinary retention, which is a painful and potentially dangerous complication requiring prompt intervention such as catheterization if spontaneous voiding does not occur within the ordered 4-hour window.
Why the other options are incorrect:
Pain rated 3 on a 0 to 10 scale described as rectal discomfort is an expected and common post-procedure finding following a transrectal prostate biopsy. Mild rectal discomfort is a normal consequence of the procedure and does not indicate a serious complication. It should be monitored and managed for comfort but does not require priority follow-up in the same way that urinary retention and malignancy-related findings do.
Blood pressure of 136/80 mm Hg is slightly above the normal range but is consistent with the client's known history of hypertension for which he is already taking lisinopril. This is not an acute or unexpected post-procedure finding and does not require priority intervention beyond continued monitoring of his blood pressure as part of routine care.
White blood cell count of 7,200/mm³ is within the normal reference range of 5,000 to 10,000/mm³, indicating no current evidence of systemic infection or significant inflammation at the time of the pre-procedure blood draw. While post-biopsy infection is a potential complication that the nurse should monitor for in the hours and days following the procedure, the current WBC is normal and does not require priority follow-up at this time.
-
Eat 500 kcal less per day to lose a pound (0.45 kg) each week.
-
Consume liquid supplements instead of food for two meals a day.
-
Plan to eat fruit for breakfast and lunch and have a regular dinner meal.
-
Lower caloric intake to 1,100 kcal per day for the first month.
Explanation
The evidence-based principle of weight loss is that a deficit of 3,500 calories equals approximately one pound of body weight. Reducing daily caloric intake by 500 kcal creates a weekly deficit of 3,500 calories, resulting in a safe and sustainable loss of approximately one pound per week. Over 4 months (approximately 16 weeks), this approach would result in a loss of approximately 16 pounds, which is close to the client's goal of 20 pounds and is achievable through a moderate, sustainable dietary modification. This recommendation aligns with evidence-based guidelines for healthy weight loss of 1 to 2 pounds per week, which preserves lean muscle mass and promotes long-term success.
Why Other Options Are Incorrect:
Consuming liquid supplements instead of food for two meals a day is not a balanced or sustainable evidence-based recommendation. Meal replacement approaches without medical supervision can lead to nutritional deficiencies, muscle loss, and rebound weight gain once normal eating patterns resume. This is not a nurse-recommended strategy without specific healthcare provider guidance.
Planning to eat only fruit for breakfast and lunch with a regular dinner is nutritionally unbalanced and does not provide adequate protein, fat, or essential nutrients earlier in the day. This approach can lead to excessive hunger, overeating at dinner, blood sugar fluctuations, and inadequate nutrient intake, making it an unsafe and unsustainable dietary recommendation.
Lowering caloric intake to 1,100 kcal per day from the current 2,000 kcal per day creates an extreme deficit of 900 kcal per day, which is considered a very low calorie diet. Such a drastic reduction is not safe without medical supervision, can cause muscle wasting, nutritional deficiencies, fatigue, and metabolic slowdown, and is not recommended as a nurse-initiated dietary intervention for a general weight loss goal.
-
Continue to provide life support until a thorough search for a guardian is completed.
-
Notify the unit manager that an emergency court order is needed to allow surgery.
-
Ask the client's friend to sign the informed consent since the client is unresponsive.
-
Carry on with surgical preparation of the client without a signed informed consent.
Explanation
Correct Answer Is:
D
In a life-threatening emergency where immediate surgery is required to save a client's life and the client is unable to provide consent due to being unresponsive, the legal and ethical doctrine of implied consent applies. Implied consent assumes that a reasonable person in the same situation would consent to life-saving treatment if they were able to do so. When no legally authorized decision-maker such as a next of kin, legal guardian, or healthcare proxy is available and the delay required to obtain consent would result in the client's death, the nurse and surgical team are legally and ethically permitted to proceed with surgery without a signed informed consent. Saving the client's life takes absolute priority in this situation.
Why the other options are incorrect:
Continuing to provide life support until a thorough search for a guardian is completed would dangerously delay the life-saving surgery that has been determined to be immediately necessary. In an acute emergency where every minute counts, waiting for a guardian search could result in the client's death, which is not an acceptable course of action when the doctrine of implied consent permits proceeding without consent.
Notifying the unit manager that an emergency court order is needed is not the first action and would cause unacceptable delays. Emergency court orders are time-consuming processes that are not feasible when immediate surgery is required to save a client's life. The doctrine of implied consent exists precisely to address situations where obtaining formal consent is not possible in time.
Asking the client's friend to sign the informed consent is legally invalid. A close friend has no legal authority to provide consent for medical procedures on behalf of another adult unless they have been specifically designated as a healthcare proxy or power of attorney for healthcare decisions. Accepting a friend's signature as informed consent would not be legally binding and could expose the healthcare team to liability.
How to Order
Select Your Exam
Click on your desired exam to open its dedicated page with resources like practice questions, flashcards, and study guides.Choose what to focus on, Your selected exam is saved for quick access Once you log in.
Subscribe
Hit the Subscribe button on the platform. With your subscription, you will enjoy unlimited access to all practice questions and resources for a full 1-month period. After the month has elapsed, you can choose to resubscribe to continue benefiting from our comprehensive exam preparation tools and resources.
Pay and unlock the practice Questions
Once your payment is processed, you’ll immediately unlock access to all practice questions tailored to your selected exam for 1 month .