HESI BSN395 Compass Exit Exam
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Free HESI BSN395 Compass Exit Exam Questions
A client presents with severe pain, redness, and swelling in the first metatarsophalangeal joint. Laboratory results indicate an elevated serum uric acid level. Which action(s) should the nurse implement to target the underlying cause of the client's symptoms? Select all that apply.
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Evaluate the client's medications to identify drugs that increase uric acid levels and promote monosodium urate crystal formation.
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Administer colchicine to reduce the neutrophil-driven inflammatory response caused by uric acid crystal deposition.
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Encourage the limitation of high-purine foods to decrease uric acid production and reduce crystal formation.
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Promote adequate hydration to support renal excretion of uric acid and lower the risk of crystal precipitation.
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Apply warm compresses to dissolve synovial fluid accumulation contributing to joint inflammation.
Explanation
Correct Answers:
(A) Evaluate the client's medications to identify drugs that increase uric acid levels and promote monosodium urate crystal formation, (C) Encourage the limitation of high-purine foods to decrease uric acid production and reduce crystal formation, and (D) Promote adequate hydration to support renal excretion of uric acid and lower the risk of crystal precipitation
The presentation of severe pain, redness, and swelling in the first metatarsophalangeal joint combined with an elevated serum uric acid level is the classic presentation of acute gouty arthritis, caused by the deposition of monosodium urate crystals in the joint space. The question specifically asks for actions that target the underlying cause, which is hyperuricemia and crystal formation, rather than symptomatic relief alone.
Evaluating the client's medications is essential because many commonly used drugs including thiazide diuretics, low-dose aspirin, cyclosporine, and niacin can significantly raise serum uric acid levels by impairing renal uric acid excretion or increasing uric acid production. Identifying and modifying or replacing these medications directly addresses one of the root causes of the elevated uric acid level.
Encouraging limitation of high-purine foods directly targets the underlying cause of hyperuricemia because purines are metabolized into uric acid in the body. Foods high in purines such as organ meats, shellfish, red meat, and alcohol particularly beer and spirits increase uric acid production and lower the threshold for crystal precipitation in joints, worsening gout. Dietary modification is a cornerstone of long-term gout management.
Promoting adequate hydration addresses the underlying cause by enhancing renal clearance of uric acid. The kidneys are responsible for excreting approximately two-thirds of uric acid produced daily, and adequate fluid intake increases urine volume, dilutes uric acid concentration, and promotes its excretion, thereby reducing the risk of crystal formation and precipitation in joints and the renal tubules.
Why the other options are incorrect:
Administering colchicine targets the inflammatory response triggered by uric acid crystal deposition rather than the underlying cause of the elevated uric acid level itself. Colchicine works by inhibiting neutrophil migration and reducing the inflammatory cascade, which addresses the symptoms of the acute gout attack but does not lower uric acid levels or prevent future crystal formation. Since the question specifically asks for actions targeting the underlying cause, colchicine does not qualify despite being an appropriate symptomatic treatment.
Applying warm compresses is incorrect on two levels. First, it does not target the underlying cause of hyperuricemia or crystal formation. Second, warm compresses are actually contraindicated in acute gout because heat increases blood flow to the already inflamed joint, worsening the inflammatory response and intensifying pain. Cold compresses are the appropriate non-pharmacological intervention for acute gout to reduce local inflammation and provide pain relief.
The nurse enters a client's room to administer oral medications and finds an unlicensed assistive personnel (UAP) providing personal care to the client, whose condition has obviously deteriorated. The client is lying in a supine position and is weak, pale, and diaphoretic. Which is the priority nursing action?
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Explain to the UAP that changes in a client's condition should be reported immediately.
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Determine why the UAP did not notify the nurse of the change in the client's condition.
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Advise the UAP to stop providing care so the nurse can assess the client's condition.
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Ask the UAP to position the client so the oral medications can be administered.
Explanation
The priority nursing action in any situation where a client has obviously deteriorated is to immediately assess the client. The client is weak, pale, and diaphoretic, which are signs of a potentially serious and life-threatening condition such as hypoglycemia, sepsis, internal bleeding, or cardiovascular compromise. Per the ABCs of nursing priority and the nursing process, assessment must come first before any other action. The nurse must stop the UAP's activity and conduct a full assessment immediately to determine the cause of the deterioration and initiate appropriate interventions.
Why the other options are incorrect:
Explaining to the UAP that changes in condition should be reported immediately is an important educational intervention but is not the priority when a client is currently in a deteriorated state. Client safety and immediate assessment take precedence over staff education, which can occur after the client's needs have been addressed.
Determining why the UAP did not notify the nurse is an administrative and supervisory concern that should be addressed after the client's immediate needs are met. Investigating communication failures is not appropriate while the client is in an acute state of deterioration requiring urgent nursing assessment.
Asking the UAP to position the client for oral medication administration is inappropriate and potentially dangerous. A client who is weak, pale, and diaphoretic should not be given oral medications until assessed, as the underlying cause of deterioration must first be identified. Administering medications to a client in an unknown deteriorated state could worsen the situation.
A client with a hip fracture is requesting pain medication prior to being repositioned in the bed. To assess the quality of the client's pain, which approach should the nurse use?
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Observe body language and movement.
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Identify effective pain relief measures.
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Provide a numeric pain scale.
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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.
A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?
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Administer the client's antidepressant medication as prescribed.
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Arrange a meeting with the family to discuss the client's situation.
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Establish a structured routine for the client to follow.
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Assess the client's ability to communicate with the other staff members.
Explanation
The priority intervention for a client with major depression is to ensure the administration of prescribed antidepressant medication. Antidepressants are the cornerstone of treatment for major depression and must be initiated promptly to begin addressing the neurochemical imbalances driving the client's symptoms. All other interventions such as routine establishment and family meetings are secondary to ensuring pharmacological treatment is started.
Why the other options are incorrect:
B. Arrange a meeting with the family to discuss the client's situation — Family involvement is an important part of the treatment plan but is not the first priority. Medication administration takes precedence in the immediate care of a newly admitted depressed client.
C. Establish a structured routine for the client to follow — A structured routine is a therapeutic intervention that supports recovery but is not the first action. The client must first receive their prescribed medication to begin addressing the underlying depression.
D. Assess the client's ability to communicate with the other staff members — Communication assessment is part of the overall evaluation but is not the priority first intervention for a client presenting with classic depressive symptoms.
Actions to rank: Cleanse the urinary meatus using the solution, swabs, and forceps provided. Don sterile gloves and prepare the sterile field. Place distal end of the catheter in sterile specimen cup and insert catheter into meatus. Open the sterile catheter kit close to the client's perineum.
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Cleanse the urinary meatus using the solution, swabs, and forceps provided.
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Don sterile gloves and prepare the sterile field.
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Place distal end of the catheter in sterile specimen cup and insert catheter into meatus.
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Open the sterile catheter kit close to the client's perineum.
Explanation
Correct Answer: Open kit → Don sterile gloves and prepare field → Cleanse urinary meatus → Insert catheter
The sterile catheter kit must first be opened close to the client's perineum to maintain sterility and ensure all supplies are within reach before the sterile field is established. Donning sterile gloves and preparing the sterile field comes next to create and maintain the aseptic environment required for the procedure. Cleansing the urinary meatus using the provided solution, swabs, and forceps is performed after the sterile field is set up, using the proper front-to-back technique to reduce bacterial contamination at the insertion site. Finally, the distal end of the catheter is placed in the sterile specimen cup before inserting the catheter into the meatus, ensuring that urine drains directly into the collection cup as soon as the bladder is entered, maintaining specimen sterility throughout.
The home health nurse is returning to visit a client with type 2 diabetes mellitus (DM) who lives alone and receives treatment for diabetic retinopathy. Which data is most important for the nurse to review in the assessment?
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Fasting blood glucose.
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Hemoglobin A1C.
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Blood lipid level.
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Weight.
Explanation
Hemoglobin A1C reflects the average blood glucose control over the past 2 to 3 months, making it the most comprehensive indicator of long-term glycemic management. For a client with diabetic retinopathy, sustained poor glucose control is the primary driver of disease progression. Since the client lives alone and self-manages their care, the A1C provides the most meaningful picture of how well blood sugar has been controlled over time, which directly impacts the progression of retinopathy.
Why the other options are incorrect:
A. Fasting blood glucose — Fasting blood glucose only reflects a single point-in-time measurement and does not provide the broader picture of long-term glucose control needed to assess retinopathy progression.
C. Blood lipid level — While lipid levels are important in diabetes management, they are not the priority assessment for a client specifically being treated for diabetic retinopathy.
D. Weight — Weight monitoring is relevant in diabetes care but is not the most critical data point when evaluating a client with diabetic retinopathy.
History and Physical:
0900: A 64-year-old male client presents to the primary care provider's office with report of frequent urination of small amounts, feeling "full" in the pelvic area, and straining with urination.
Past Medical History: Hypertension, type 2 diabetes mellitus, coronary artery disease, angina, anemia.
Allergies: Sulfa drugs.
Medications: Atenolol 25 mg PO daily, metformin 500 mg PO twice daily with meals, aspirin 81 mg PO daily, lisinopril 10 mg PO daily, ferrous sulfate 325 mg PO daily, nitroglycerin 400 mcg sublingual spray every 3 to 5 minutes as needed, not to exceed 3 metered sprays in 15 minutes.
Review of Systems: Head, eyes, ears, nose, throat (HEENT): Denies symptoms. Cardiovascular: Denies symptoms. Neurological: Moves all extremities without difficulty. Respiratory: Denies symptoms. Gastrointestinal: Denies symptoms or changes in bowel pattern. Integumentary: Denies symptoms. Urinary: Reports voiding approximately 15 times a day with small amounts, feeling of fullness in the pelvic area, straining with urination. Denies burning with urination.
Physical Exam: General appearance: Adult male client, alert and oriented to time, person, and place. HEENT: Within normal limits. Neck: Within normal limits. Cardiovascular: Heart sounds regular, S1 and S2. Neurological: Pupils equal, round, reactive to light and accommodation.
Nurses' Notes:
0910: Client appears anxious. Assisted provider to set up for prostate examination and provided support to the client during the procedure. Client reported 3 on a 0 to 10 scale of tenderness upon prostate palpation.
0920: Client voided 50 mL of clear yellow urine, specimen obtained for urinalysis. Blood draw completed for laboratory testing. Post void bladder scan completed with noted residual of 50 mL.
1 week later 0900: Client returns to the office 1 week later to review laboratory and diagnostic findings.
Laboratory Results:
Basic Metabolic Profile: Sodium 140 mEq/L (reference range 136 to 145 mEq/L). Potassium 4.5 mEq/L (reference range 3.5 to 5.0 mEq/L). Chloride 102 mEq/L (reference range 98 to 106 mEq/L). CO2 24 mEq/L (reference range 23 to 30 mEq/L). Glucose 109 mg/dL (reference range 70 to 110 mg/dL). Blood urea nitrogen (BUN) 21 mg/dL (reference range 10 to 20 mg/dL). Creatinine serum 1.3 mg/dL (reference range 0.6 to 1.2 mg/dL).
Prostate-specific antigen (PSA): 10 ng/mL, reference range 0 to 4 ng/mL.
Urinalysis: Appearance clear, color yellow (reference amber yellow). White blood cells 0 (reference range 0 to 4 per low-power field). Red blood cells 1 (reference range less than or equal to 2). pH 6.1 (reference range 4.6 to 8). Protein 6 mg/dL (reference range 0 to 8 mg/dL). Specific gravity 1.009 (reference range 1.005 to 1.03). Leukocyte esterase negative. Nitrites negative. Ketones negative. Crystals negative. Casts none. Red blood cell casts none. Glucose negative. Bilirubin none. Osmolality urine 1,000 mOsm/kg (reference range 50 to 1,200 mOsm/kg).
Flow Sheet:
0910 — Vital Signs: Temperature 97.8°F (36.5°C), heart rate 72 beats/minute, respirations 20 breaths/minute, blood pressure 130/74 mm Hg, oxygen saturation on room air 97%, pain 3 on a 0 to 10 scale.
0920: Client voided 50 mL of clear yellow urine.
1 week later 0900 — Vital Signs: Temperature 98.1°F (36.7°C), heart rate 69 beats/minute, respirations 20 breaths/minute, blood pressure 132/80 mm Hg, oxygen saturation on room air 97%, pain 0 on a 0 to 10 scale.
Question : The nurse is considering goals for this client related to anticipated drug therapy. Choose the most likely options for the information missing from the statement by selecting from the list of options provided.
The nurse determines that appropriate goals for this client are to ___ and ___.
Word choices: improve urine clarity, increase urine flow, reduce creatinine level, reduce prostate-specific antigen (PSA) level
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improve urine clarity
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increase urine flow
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reduce creatinine level
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reduce prostate-specific antigen (PSA) level
Explanation
The primary therapeutic goals for this client with lower urinary tract symptoms caused by benign prostatic hyperplasia and an elevated PSA are directly related to improving urinary function and addressing the elevated PSA. Increasing urine flow is the most immediate and clinically relevant goal because the client's primary symptoms are urinary hesitancy, straining, frequent small voids, and incomplete bladder emptying, all of which indicate obstructed and reduced urine flow. Drug therapy with alpha-adrenergic blockers and/or 5-alpha-reductase inhibitors is directed at relieving this obstruction and increasing the rate and ease of urination. Reducing the PSA level is a goal of 5-alpha-reductase inhibitor therapy because these medications reduce prostate tissue volume and DHT levels, which in turn lowers PSA production. Monitoring PSA reduction over time also helps evaluate treatment response and, importantly, it must be noted that a PSA of 10 ng/mL in a client on a 5-alpha-reductase inhibitor should be interpreted as equivalent to double the measured value when assessing for prostate cancer risk.
Why the other options are incorrect:
Improving urine clarity is not a relevant treatment goal because the client's urinalysis showed clear yellow urine with all values within normal limits, indicating there is no current problem with urine clarity requiring correction through drug therapy.
Reducing creatinine level is a monitoring goal rather than a direct therapeutic goal of the prescribed prostate drug therapy. While the elevated creatinine of 1.3 mg/dL requires monitoring, the pharmacological treatments for BPH do not directly lower serum creatinine. Creatinine reduction would require management of the underlying renal insufficiency and relief of urinary obstruction rather than being a direct drug therapy goal.
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.
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PSA level of 12.6 ng/mL.
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Minimal urine output since the procedure.
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Pain rated 3 on a 0 to 10 scale described as rectal discomfort.
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Blood pressure of 136/80 mm Hg.
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Hypoechoic lesion identified in the peripheral zone of the prostate.
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Continued difficulty initiating urination post-procedure.
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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.
A client diagnosed with pancreatitis is reporting severe epigastric pain and intense nausea. After the nurse administers a narcotic analgesic and an antiemetic, the client insists on sitting up and leaning forward. Which action should the nurse implement?
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Raise head of bed until at a 90 degree angle.
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Reinforce bed rest until analgesic is effective.
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Position bedside table for client to lean across.
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Place bed in reverse trendelenburg position.
Explanation
Clients with pancreatitis often find that leaning forward reduces pain by relieving pressure on the inflamed pancreas. Since the client is insisting on this position, the nurse should support this comfort measure by placing the bedside table in front of the client to lean on safely. This respects the client's comfort preference while maintaining safety.
Why the other options are incorrect:
A. Raise head of bed until at a 90 degree angle — While elevating the head of the bed provides some relief, a rigid 90-degree position does not allow the client to lean forward comfortably the way a bedside table does.
B. Reinforce bed rest until analgesic is effective — Forcing the client to remain flat when they are expressing a need to lean forward disregards the client's comfort and autonomy. Leaning forward is a known pain-relieving position for pancreatitis.
D. Place bed in reverse trendelenburg position — This position elevates the head and lowers the legs but does not allow the client to lean forward, and is not specifically indicated for pancreatitis pain management.
A client on the unit is scheduled for weighing. The nurse asks an unlicensed assistant to weigh a client. The assistant acknowledges and accepts the assignment. The nurse six hours later reviews the client's record and notes a 4.2 kg difference in weight from the previous day. The nurse should be most concerned with which right of delegation?
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Supervision.
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Direction/communication.
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Person.
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Circumstance.
Explanation
The right of circumstance requires the nurse to ensure that the conditions and environment are appropriate for the delegated task to be carried out safely and accurately. A 4.2 kg weight difference in one day is a clinically significant and unlikely finding that suggests the task was not performed under appropriate circumstances, such as using a properly calibrated scale, weighing at the correct time, or following the correct procedure. The nurse failed to verify that the circumstances were suitable for accurate weight measurement.
Why the other options are incorrect:
A. Supervision — Supervision involves monitoring the performance of the delegated task. While supervision is relevant, the more specific concern here is whether the right conditions were in place for the task to be done correctly, which points to circumstance.
B. Direction/communication — Direction and communication refer to providing clear instructions about how the task should be performed. The question does not indicate that unclear instructions were the issue, making this a less specific concern than circumstance.
C. Person — The right of person refers to ensuring the task is delegated to someone competent to perform it. There is no indication that the UAP lacked the competency to weigh a client, making this the least applicable right in this scenario.
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