HESI BSN395 Compass Exit Exam
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Free HESI BSN395 Compass Exit Exam Questions
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Record a minimal risk for falls, documenting the client's statement.
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Place the client on a high fall risk protocol because of advanced age.
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Inform the client that falls occur more often in the hospital than at home.
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Continue to obtain client data needed to complete the fall risk survey.
Explanation
Correct Answer: (D) Continue to obtain client data needed to complete the fall risk survey
A fall risk assessment is a comprehensive, standardized process that requires collecting multiple data points including medication review, gait and balance assessment, vision status, cognitive function, environmental factors, and history of near-falls in addition to reported falls. A client's self-report of never falling is only one piece of data and is insufficient to determine overall fall risk, particularly in an older adult. Many older adults do not report near-falls or do not recognize their own fall risk factors. The nurse must complete the full assessment tool before making any determination about the client's fall risk level to ensure accurate and thorough clinical judgment.
Why the other options are incorrect:
Recording a minimal risk based solely on the client's statement is premature and potentially unsafe. The client's self-report must be considered alongside objective assessment data from the complete fall risk survey before any risk determination can be documented.
Placing the client on a high fall risk protocol based solely on advanced age without completing the full assessment is not evidence-based practice. Age alone is a contributing factor to fall risk but is not sufficient justification for automatically categorizing a client as high risk without a complete individualized assessment.
Informing the client that falls occur more often in the hospital than at home is not the priority action and does not address the immediate clinical need to complete the fall risk assessment. While this statement may be factually relevant for patient education, it does not fulfill the nurse's responsibility to complete the required assessment.
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.
Question: Click to indicate which education instructions the nurse should include to prevent future cellulitis and promote healing when preparing the client for discharge. Each column must have at least one response selected.
Instructions and their categories:
Refrain from sharing towels and razors with others — Promote healing / Prevent future cellulitis
Shower daily with antibacterial soap — Promote healing / Prevent future cellulitis
Wash hands before and after touching open wounds including bug bites — Promote healing / Prevent future cellulitis
Complete full course of antibiotic therapy — Promote healing / Prevent future cellulitis
Eat foods which contain protein and vitamin C — Promote healing / Prevent future cellulitis
- Refrain from sharing towels and razors with others — Prevent future cellulitis
- Shower daily with antibacterial soap — Prevent future cellulitis
- Wash hands before and after touching open wounds including bug bites — Prevent future cellulitis
- Complete full course of antibiotic therapy — Promote healing
- Eat foods which contain protein and vitamin C — Promote healing
Explanation
Correct Answers:
Refrain from sharing towels and razors with others — Prevent future cellulitis
Shower daily with antibacterial soap — Prevent future cellulitis
Wash hands before and after touching open wounds including bug bites — Prevent future cellulitis
Complete full course of antibiotic therapy — Promote healing
Eat foods which contain protein and vitamin C — Promote healing
Refraining from sharing towels and razors with others prevents future cellulitis because shared personal items can harbor and transfer bacteria such as Staphylococcus aureus and Streptococcus directly onto the skin, creating a pathway for bacterial entry especially in a client who is diabetic and immunocompromised. This is a hygiene measure that reduces the risk of introducing new pathogens to the skin surface.
Showering daily with antibacterial soap prevents future cellulitis by reducing the bacterial load on the skin surface. Regular cleansing removes bacteria, dead skin cells, and debris that can accumulate and increase the risk of infection, particularly important for a diabetic client whose skin integrity and immune response are already compromised.
Washing hands before and after touching open wounds including bug bites prevents future cellulitis by reducing the risk of introducing bacteria into any break in the skin. Open wounds and insect bites are potential portals of entry for bacteria, and hand hygiene is one of the most effective measures to prevent bacterial contamination of these sites.
Completing the full course of antibiotic therapy promotes healing by ensuring the bacterial infection is completely eradicated. Stopping antibiotics early when symptoms improve is a common mistake that allows surviving bacteria to repopulate and potentially develop antibiotic resistance, leading to treatment failure, relapse of infection, and a more severe or harder-to-treat recurrence of cellulitis.
Eating foods containing protein and vitamin C promotes healing because protein provides the essential amino acids required for tissue repair, immune cell production, and collagen synthesis, while vitamin C is a necessary cofactor for collagen cross-linking and enhances the function of immune cells including neutrophils and lymphocytes. In a diabetic client with impaired wound healing and an active skin infection, optimizing nutrition directly accelerates recovery and supports skin integrity restoration.
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Duloxetine.
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Fluoxetine.
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Venlafaxine.
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Escitalopram.
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Bupropion.
Explanation
Correct Answers: (A) Duloxetine, (C) Venlafaxine, and (D) Escitalopram
Sertraline is a selective serotonin reuptake inhibitor (SSRI) that is a first-line treatment for GAD, but when a client fails to respond adequately after an appropriate trial, alternative medications with evidence-based efficacy for GAD should be considered. Duloxetine is a serotonin-norepinephrine reuptake inhibitor (SNRI) that is FDA-approved for GAD and is a well-established alternative when SSRIs are ineffective. Venlafaxine is also an SNRI that is FDA-approved for GAD and has strong evidence supporting its use as an alternative to SSRIs in clients with persistent anxiety symptoms. Escitalopram is another SSRI that is FDA-approved for GAD and may be effective in clients who did not respond to sertraline, as different SSRIs can have varying responses in individual clients due to differences in receptor binding profiles and pharmacokinetics.
Why Other Options Are Incorrect:
Fluoxetine is an SSRI with FDA approval for major depressive disorder, obsessive-compulsive disorder, panic disorder, and bulimia nervosa, but it does not have FDA approval specifically for GAD and is not considered a standard alternative for GAD treatment.
Bupropion is an atypical antidepressant that works primarily by inhibiting the reuptake of norepinephrine and dopamine. It is FDA-approved for major depressive disorder and smoking cessation but is not approved for GAD. Additionally, bupropion can actually worsen anxiety symptoms due to its stimulating dopaminergic and noradrenergic effects, making it an inappropriate and potentially harmful alternative for a client with GAD.
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Asymmetrical breast size.
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Nipple inversion.
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Cyclic tenderness.
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Dimpling of the skin.
Explanation
Correct Answer: (D) Dimpling of the skin
Dimpling of the skin over the breast is a classic and significant warning sign of breast cancer. It occurs when a tumor beneath the skin infiltrates and shortens the Cooper's ligaments, which are the fibrous connective tissue bands that support the breast. This pulling effect causes the overlying skin to pucker or dimple, creating what is often described as an orange peel appearance (peau d'orange). Skin dimpling is not a normal variation and should always be investigated further as it is strongly associated with underlying malignancy.
Why Other Options Are Incorrect:
Asymmetrical breast size is a common normal variation in women and is not by itself indicative of breast cancer. While a sudden or new change in breast size warrants evaluation, having one breast larger than the other is frequently a benign finding.
Nipple inversion can be a normal anatomical variant that has been present since puberty. While new onset nipple inversion in an adult can be a warning sign of breast cancer, the question states that both nipples are inverted, suggesting this is a bilateral long-standing variant rather than a new pathological change associated with malignancy.
Cyclic tenderness that follows the menstrual cycle is typically associated with fibrocystic breast changes, a benign condition influenced by hormonal fluctuations. Breast cancer pain is generally non-cyclic and localized rather than generalized and cyclical.
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:
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.
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Take before bedtime.
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Administer with a meal.
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Store at room temperature.
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Crush to increase absorption.
Explanation
Correct Answer: (A) Take before bedtime
Zolpidem is a sedative-hypnotic medication used for the short-term treatment of insomnia. It works by enhancing the effect of gamma-aminobutyric acid (GABA) at the GABA-A receptor, producing a calming effect on the brain that induces sleep. Because it acts rapidly and causes significant sedation, the client must be instructed to take it immediately before going to bed and only when they are able to get a full 7-8 hours of sleep. Taking it at any other time of day creates a serious risk of falls, impaired coordination, and dangerous drowsiness.
Why Other Options Are Incorrect:
Administering zolpidem with a meal is incorrect. Zolpidem should be taken on an empty stomach because food, especially a high-fat meal, delays its absorption and significantly reduces its effectiveness. Taking it with food can delay the onset of sleep-inducing effects.
Storing at room temperature is a general medication storage guideline that applies to many drugs and is not specific or particularly important teaching information for zolpidem. While it is not incorrect, it is not the most essential or priority information the nurse should include in client education about this medication.
Crushing zolpidem to increase absorption is incorrect and potentially dangerous. Zolpidem extended-release tablets must never be crushed because crushing destroys the extended-release mechanism, causing the entire dose to be released at once, which can lead to an overdose, excessive sedation, and respiratory depression. Even immediate-release formulations should not be crushed as this alters the intended delivery of the medication.
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Neurology unit supervisor.
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Adult nurse practitioner.
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Nurse case manager.
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Risk management nurse.
Explanation
A nurse case manager is specifically trained and responsible for coordinating the progression of care across the entire healthcare continuum for clients with complex, long-term, or multidisciplinary needs. A spinal cord injury following a motor vehicle collision is a catastrophic event that will require coordination of multiple healthcare disciplines including neurology, rehabilitation medicine, physical therapy, occupational therapy, respiratory therapy, social work, and community resources. The nurse case manager serves as the central coordinator who facilitates communication among all team members, arranges appropriate level-of-care transitions, ensures continuity of care, and helps the client and family navigate the complex healthcare system from acute care through rehabilitation and community reintegration.
Why the other options are incorrect:
The neurology unit supervisor oversees the operations and staffing of the neurology unit but is not specifically responsible for coordinating the overall progression and continuity of an individual client's care across disciplines and care settings.
The adult nurse practitioner provides advanced clinical assessment, diagnosis, and treatment within their scope of practice but does not have the specific role of coordinating the overall progression of care and resource management across the healthcare continuum the way a case manager does.
The risk management nurse focuses on identifying, evaluating, and mitigating risks to the organization related to patient safety, legal liability, and regulatory compliance. While a spinal cord injury from a motor vehicle accident may eventually involve risk management for legal purposes, the risk management nurse is not responsible for coordinating the clinical progression of the client's care.
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Confirm lead wires are secured to pacemaker generator.
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Check the adhesion of the pacemaker pads.
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Change the batteries in the pacemaker.
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Shave chest and replace pacemaker pads.
Explanation
Correct Answer: (B) Check the adhesion of the pacemaker pads
Failure to capture in a transcutaneous pacemaker means that the electrical impulse delivered by the pacemaker is not successfully depolarizing the myocardium and producing a mechanical contraction. The most common and easily correctable cause of failure to capture in a transcutaneous pacemaker is poor skin contact between the pacemaker pads and the client's skin, which increases impedance and prevents adequate current delivery to the heart. Checking pad adhesion is the first and simplest intervention because poor pad contact is the most frequent cause of intermittent capture failure and can be quickly identified and corrected without any specialized equipment or additional interventions.
Why the other options are incorrect:
Confirming that lead wires are secured to the pacemaker generator is an appropriate troubleshooting step but is secondary to checking pad adhesion, as loose lead wire connections are less common than poor pad adhesion as a cause of capture failure in transcutaneous pacing.
Changing the batteries in the pacemaker is a reasonable troubleshooting measure if pad adhesion is confirmed to be adequate and capture failure persists, but it is not the first intervention because battery depletion is less likely to be the cause of intermittent capture failure compared to pad contact issues.
Shaving the chest and replacing pacemaker pads is indicated if the initial pad adhesion check reveals that chest hair is preventing adequate contact between the pads and the skin, but this is a secondary intervention that would only be implemented after confirming that poor adhesion is indeed the problem. Shaving and replacing pads before assessing the current pad adhesion would be premature and unnecessarily disruptive.
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Assess the client's ability to use a numeric pain scale.
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Assess the abdomen for bowel sounds.
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Initiate the dosage lockout mechanism on the PCA pump.
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Instruct the client to use the medication before the pain becomes severe.
Explanation
Correct Answer: (C) Initiate the dosage lockout mechanism on the PCA pump.
The dosage lockout mechanism is a critical safety feature of the PCA pump that prevents the client from administering doses too frequently and protects against opioid overdose. Initiating this safety mechanism is the highest priority action when setting up morphine PCA therapy as it ensures the client cannot exceed the prescribed dosage parameters, preventing potentially life-threatening respiratory depression and overdose.
Why Other Options are Incorrect:
A. Assess the client's ability to use a numeric pain scale. While pain assessment is important for ongoing evaluation, it is not the priority action when initiating PCA therapy. The safety of the delivery system must be ensured first before any other assessments or instructions are provided.
B. Assess the abdomen for bowel sounds. Monitoring for decreased bowel sounds is an important ongoing assessment due to the constipating effects of opioids, but this is not the priority action at the time of PCA initiation. Safety setup of the pump takes precedence.
D. Instruct the client to use the medication before the pain becomes severe. While patient education about proactive pain management is beneficial, it is not the first priority. The nurse must first ensure the pump is set up correctly and safely with the lockout mechanism activated before providing any client education.
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