HESI BSN395 Compass Exit Exam
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Free HESI BSN395 Compass Exit Exam Questions
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Engage in vigorous aerobic exercise at least 3-4 times a week.
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Avoid cigarettes and/or tobacco products and second hand smoke.
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You should drink at least 3-4 liters of non-caffeinated liquid a day.
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Receive a yearly pneumonia vaccination.
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Always wear socks and gloves when outside on cold days.
Explanation
Correct Answers: (B) Avoid cigarettes and/or tobacco products and second hand smoke, (C) You should drink at least 3-4 liters of non-caffeinated liquid a day, (D) Receive a yearly pneumonia vaccination, and (E) Always wear socks and gloves when outside on cold days
Sickle cell crisis is triggered by factors that cause hypoxia, dehydration, infection, or exposure to cold, all of which promote sickling of red blood cells. Avoiding cigarettes and tobacco products is essential because smoking causes vasoconstriction and reduces oxygen delivery to tissues, directly triggering sickling. Maintaining adequate hydration with 3-4 liters of non-caffeinated fluid daily prevents the blood from becoming viscous and reduces the risk of red blood cells sickling and clumping together in vessels. Receiving a yearly pneumonia vaccination is critical because clients with sickle cell disease have functional asplenia, meaning the spleen is damaged from repeated sickling episodes and cannot effectively filter encapsulated bacteria such as Streptococcus pneumoniae, making them highly susceptible to life-threatening infections that can trigger a crisis. Wearing socks and gloves in cold weather prevents peripheral vasoconstriction caused by cold exposure, which is a well-known precipitating factor for sickle cell crisis because it reduces blood flow to the extremities and promotes sickling.
Why Other Options Are Incorrect:
Engaging in vigorous aerobic exercise at least 3-4 times a week is incorrect and potentially dangerous for a client with sickle cell disease. Vigorous exercise increases oxygen demand, causes dehydration through sweating, and promotes lactic acid buildup, all of which can trigger a sickle cell crisis. Moderate, low-intensity activity with adequate hydration is recommended instead, and the client should be advised to avoid strenuous exertion.
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Administer prescribed PRN sleep medications.
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Encourage use of prescribed analgesic perineal sprays.
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Administer prescribed stool softener.
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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.
Reference Range: Hemoglobin 14 to 18 g/dL (140 to 180 g/L) Potassium 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L) White Blood Cell 5,000 to 10,000/mm³ (5 to 10 x 10⁹/L)
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Move Client D into an isolation room 24 hours before surgery.
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Ask the dietitian to add a banana to Client C's breakfast tray.
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Verify that Client B has two units of packed red blood cells (RBCs) available.
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Increase Client A's oxygen to 4 L/minute via nasal cannula.
Explanation
Correct Answer Is:
C
Client B has a postoperative hemoglobin of 8.2 mg/dL, which is significantly below the normal reference range of 14 to 18 g/dL. This indicates that the client has developed postoperative anemia, likely from surgical blood loss, which is a serious and potentially life-threatening condition. A hemoglobin of 8.2 g/dL can compromise oxygen delivery to tissues and organs, leading to hypoxia, hemodynamic instability, and cardiovascular compromise, particularly in the postoperative period when the body's demand for oxygen is increased. Verifying that two units of packed red blood cells are available ensures that blood transfusion therapy is ready to be initiated promptly if the client's condition deteriorates further, making this the most urgent and appropriate nursing intervention among the four clients.
Why the other options are incorrect:
Moving Client D into an isolation room 24 hours before surgery is not indicated based on the findings provided. While Client D's WBC count of 14,000/mm³ is elevated above the normal range of 5,000 to 10,000/mm³, suggesting possible infection or inflammation, isolation is not the standard intervention for an elevated WBC before appendectomy. The elevated WBC is likely related to the appendicitis itself and is expected in this context. This finding should be reported to the healthcare provider but does not require isolation.
Asking the dietitian to add a banana to Client C's breakfast tray would be appropriate if the client had hypokalemia, as bananas are rich in potassium. However, Client C's potassium level of 3.8 mEq/L is within the normal reference range of 3.5 to 5.0 mEq/L. There is no indication for potassium supplementation in this client, making this intervention unnecessary.
Increasing Client A's oxygen to 4 L/minute via nasal cannula is contraindicated in a client with emphysema. Clients with chronic obstructive pulmonary disease such as emphysema rely on a hypoxic drive to breathe, meaning their respiratory stimulus is driven by low oxygen levels rather than high carbon dioxide levels as in a normal client. Administering high-flow oxygen to these clients can suppress their respiratory drive, leading to respiratory depression and hypercapnia. Furthermore, Client A's oxygen saturation of 94% on room air is within an acceptable range for a client with emphysema, and increasing supplemental oxygen is not indicated at this time.
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Mechanical soft.
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Pureed diet.
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Full liquid.
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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.
Explanation
Correct Answer:
The diaphragm of the stethoscope should be placed over the popliteal artery, located in the popliteal fossa behind the knee on the posterior aspect of the left leg.
When measuring blood pressure using the thigh as the cuff site, the same principles apply as when measuring at the arm. The blood pressure cuff is applied to the thigh with the bladder of the cuff positioned over the femoral artery on the anterior thigh. The stethoscope diaphragm is then placed over the popliteal artery in the popliteal fossa, which is the hollow space behind the knee joint, to auscultate the Korotkoff sounds as the cuff is deflated. The popliteal artery is the continuation of the femoral artery distal to the thigh, making it the correct auscultation site when the thigh cuff method is used. The client should be positioned prone or supine with the knee slightly flexed to facilitate access to the popliteal fossa.
Nurses' Notes:
2340: Client assessed. Child is fussy and grimacing and is being held by her mother. Assessment — Neurological: Alert and oriented to caregiver. Eyes reactive to light, appears irritable.
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).
Imaging Studies:
Day 2 — 0020: Chest x-ray: hyperinflation of the lungs.
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).
The nurse considers the mother's concerns about feeding.
Select the 3 items that the nurse could do to facilitate feeding.
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Keep infant at 45° angle.
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Offer 10 mL of formula using a syringe.
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Remove oxygen during feeding time.
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Suction with a bulb syringe.
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Instill drops in nasal passages.
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Request the healthcare provider prescribe a feeding tube.
Explanation
Correct Answers: (A) Keep infant at 45° angle, (B) Offer 10 mL of formula using a syringe, and (D) Suction with a bulb syringe
For an infant with RSV bronchiolitis who is having difficulty feeding due to nasal congestion and respiratory distress, the nurse should use interventions that support safe oral feeding without compromising the airway. Keeping the infant at a 45° angle uses gravity to reduce nasal congestion and decreases the risk of aspiration during feeding. Offering small amounts of formula (10 mL) via syringe allows the infant to take in nutrition at a manageable pace without overexerting itself or compromising breathing. Suctioning with a bulb syringe clears nasal secretions before feeding, which is critical because infants are obligate nose breathers and congestion directly impairs their ability to feed and breathe simultaneously.
Why the other options are incorrect:
C. Remove oxygen during feeding time — This is dangerous and contraindicated. The infant's SpO₂ is only 93% on 1 L/min oxygen; removing oxygen during feeding could cause a dangerous drop in oxygen saturation and worsen respiratory distress.
E. Instill drops in nasal passages — Saline nasal drops are sometimes used, but they are not among the priority interventions listed and would need a specific order. Bulb syringe suctioning is the more direct and immediately appropriate intervention for clearing secretions.
F. Request the healthcare provider prescribe a feeding tube — A feeding tube is not indicated at this time. The infant is still able to take oral feeds with proper positioning and suctioning. A feeding tube would only be considered if oral feeding attempts fail completely or the infant's respiratory status deteriorates further.
1100 — Reason for visit: A 35-year-old primagravida who presented reporting decreased fetal movement for the past few hours. Obstetric history: Is 40 weeks pregnant, has had no pregnancy complications, and received regular prenatal care starting at 11 weeks gestation. Assessment — Reproductive: Bedside ultrasound performed. Fetus in vertex presentation. No fetal cardiac movement seen. No heartbeat on Doppler mode. Fetal movements also absent.
Nurses' Notes:
1030: Client presented to antepartum unit stating "I haven't felt my baby move for a while, maybe a few hours." Reported no vaginal bleeding, leaking fluid, cramping, low back pain, or pelvic pressure. Reported no complications during pregnancy. External electronic fetal monitor applied. Unable to locate fetal heart tones. Doppler ultrasound stethoscope used, and still unable to locate fetal heart tones. Healthcare provider (HCP) notified.
1040: HCP at bedside. Transabdominal ultrasound performed. Discussed diagnosis of fetal demise with client and partner.
1130: HCP discussing plan of care and options for labor induction. Client requests to induce labor as soon as possible. Cervical exam performed by provider. Reports cervix 3 cm dilated, 50% effaced, -1 station.
1330: Oxytocin infusing. Artificial rupture of membranes performed by provider, thick meconium noted. Reports cervix dilated 5 cm, 75% effaced.
2015: Birth of stillborn male at 2000. Single knot in umbilical cord noted. Placenta expulsed at 2005, intact. Infant being held by client, skin to skin. Client and partner crying while looking at baby.
Flow Sheet:
1030 — Vital Signs: Temperature 98.8°F (37.1°C), heart rate 84 beats/minute, respirations 18 breaths/minute, blood pressure 124/82 mm Hg, oxygen saturation on room air 98%, pain 0 on a 0 to 10 scale.
Question: For each potential nurse's statement, click to indicate whether the statement is therapeutic or nontherapeutic. Each row must have only one response option selected.
Statement 1: "I feel so sorry for you and your family."
Statement 2: "Be thankful you can have another baby."
Statement 3: "I just know you are feeling totally devastated."
Statement 4: "I can sit with you for awhile if you would like."
Statement 5: "What can I do for you right now?"
Statement 6: "You will feel better if you give it some time."
- Statement 1: "I feel so sorry for you and your family."
- Statement 2: "Be thankful you can have another baby."
- Statement 3: "I just know you are feeling totally devastated."
- Statement 4: "I can sit with you for awhile if you would like."
- Statement 5: "What can I do for you right now?"
- Statement 6: "You will feel better if you give it some time."
Explanation
Correct Answers:
"I feel so sorry for you and your family." — Nontherapeutic
"Be thankful you can have another baby." — Nontherapeutic
"I just know you are feeling totally devastated." — Nontherapeutic
"I can sit with you for awhile if you would like." — Therapeutic
"What can I do for you right now?" — Therapeutic
"You will feel better if you give it some time." — Nontherapeutic
"I can sit with you for awhile if you would like" is therapeutic because it offers the client the nurse's presence and support without making assumptions or placing conditions on the interaction. Therapeutic presence is one of the most powerful interventions a nurse can offer to a grieving client. It communicates empathy, availability, and unconditional support, allowing the client to feel less alone in their grief without the nurse imposing words or solutions onto an experience that cannot be fixed.
"What can I do for you right now?" is therapeutic because it is an open-ended, client-centered question that empowers the grieving client to identify and express their own needs in the moment. It respects the client's autonomy and acknowledges that the nurse is present and ready to help in whatever way the client needs, without making assumptions about what those needs are. This is a fundamental principle of therapeutic communication in grief support.
"I feel so sorry for you and your family" is nontherapeutic because while it is well-intentioned, expressing personal sorrow shifts the focus from the client's experience to the nurse's feelings. Therapeutic communication keeps the focus on the client, and statements that center the nurse's emotions can unintentionally make the client feel responsible for managing the nurse's distress in addition to their own grief.
"Be thankful you can have another baby" is nontherapeutic because it minimizes the profound loss the client is experiencing by redirecting their grief toward a future possibility. This statement is dismissive of the client's current pain, invalidates their grief over the specific loss of this baby, and implies that the loss is replaceable. No future pregnancy can replace the child that was lost, and this statement can cause significant emotional harm to a grieving parent.
"I just know you are feeling totally devastated" is nontherapeutic because it presumes to know exactly how the client is feeling. Every person's grief is unique and individual, and making assumptions about another person's emotional experience, even empathetic ones, can feel invalidating if the client's actual feelings differ from what the nurse projects onto them. Therapeutic communication uses open-ended statements that invite the client to share their own feelings rather than having their feelings assumed for them.
"You will feel better if you give it some time" is nontherapeutic because it trivializes the depth of the client's grief by implying it is temporary and will resolve on its own with the passage of time. This statement can make the client feel that their grief is not being taken seriously and that they should simply wait for the pain to pass rather than receiving active compassionate support. It offers false reassurance and closes down rather than opens up the therapeutic conversation.
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Importance of recording daily weights.
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Events requiring steroid dose adjustments.
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Adherence to a high fiber, low fat diet.
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Need to check temperature daily.
Explanation
Addison's disease is primary adrenal insufficiency characterized by insufficient production of cortisol and aldosterone by the adrenal glands. Clients with Addison's disease require lifelong corticosteroid replacement therapy, and a critical component of self-management education is teaching the client to recognize situations that require temporary increases in their steroid dose. Physical and psychological stressors such as illness, fever, infection, surgery, injury, and significant emotional stress dramatically increase the body's cortisol requirements. If steroid doses are not adjusted upward during these times, the client is at risk for an Addisonian crisis, a life-threatening acute adrenal insufficiency characterized by severe hypotension, hypoglycemia, hyponatremia, and cardiovascular collapse. This is the most critical and potentially life-saving self-management information for a client with Addison's disease.
Why the other options are incorrect:
Recording daily weights is a monitoring activity relevant to conditions involving fluid retention such as heart failure, chronic kidney disease, and cirrhosis. While clients with Addison's disease may experience weight changes related to cortisol and aldosterone deficiency, daily weight monitoring is not the priority self-management instruction for this condition.
Adherence to a high fiber, low fat diet is a dietary recommendation for conditions such as hyperlipidemia, cardiovascular disease, and colorectal cancer prevention. It is not a specific or priority dietary instruction for Addison's disease. Clients with Addison's disease are more specifically instructed about adequate sodium intake due to aldosterone deficiency causing sodium wasting.
Checking temperature daily is a general wellness monitoring activity and is not a specific or priority self-management instruction for Addison's disease. While fever can signal infection that may require steroid dose adjustment, daily temperature monitoring is not the most critical piece of self-management information compared to knowing when and how to adjust steroid doses.
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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.
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Allergy test.
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Electromyography.
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Skin biopsy.
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Complete blood count.
Explanation
Correct Answer Is:
D
Pinpoint, red, round spots on the skin are called petechiae, which are caused by bleeding under the skin from ruptured capillaries. In a client receiving zidovudine, a nucleoside reverse transcriptase inhibitor (NRTI) used in HIV treatment, petechiae are a significant warning sign of thrombocytopenia, a dangerous reduction in platelet count that is a known serious adverse effect of zidovudine. Zidovudine suppresses bone marrow function, which can reduce production of all blood cell lines including platelets. A complete blood count will reveal the platelet count and confirm whether thrombocytopenia is present, and this result must be reported to the healthcare provider immediately so the medication can be adjusted or discontinued to prevent life-threatening bleeding complications such as intracranial hemorrhage.
Why the other options are incorrect:
An allergy test evaluates hypersensitivity reactions and would not provide the relevant information needed to investigate petechiae in a client on zidovudine. The presentation is more consistent with a hematologic adverse drug effect than an allergic reaction, which would typically present with urticaria, angioedema, or anaphylaxis rather than petechiae.
Electromyography measures the electrical activity of muscles and nerves and is completely unrelated to the skin manifestation of petechiae or the hematologic effects of zidovudine. It would provide no useful diagnostic information in this situation.
A skin biopsy involves taking a tissue sample from the skin and while it could theoretically identify the nature of a skin lesion, it is not the priority diagnostic test for petechiae in a client on a medication known to cause bone marrow suppression. The complete blood count is faster, less invasive, and directly addresses the most likely and most dangerous cause of the petechiae.
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