Nursing school just got easier. EXACT HESI Compass Exit B Exam exam questions with verified answers. Study what actually matters and pass with confidence.
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Purchase For $30/monthNursing school just got easier. EXACT HESI Compass Exit B Exam exam questions with verified answers. Study what actually matters and pass with confidence.
The charge nurse in an extended care facility is organizing unit activities for the day. Which action may be safely delegated to the practical nurse (PN)?
Evaluate client teaching through return demonstration.
Establish blood pressure parameters for client monitoring.
Evaluate a staff member providing wound care.
Measure the client's body weight each morning.
Correct Answer: D. Measure the client's body weight each morning.
Explanation:
The practical nurse (PN) may safely be delegated routine, stable-care tasks such as measuring and recording daily body weight. This activity does not require clinical judgment or independent decision-making. Tasks involving assessment, evaluation, or establishing parameters (as in options A, B, and C) fall within the scope of the registered nurse (RN), who is responsible for interpreting data, making clinical decisions, and supervising care quality. The PN’s role focuses on implementing nursing care under RN direction.
A client with a history of gout presents to the clinic with an inflamed left knee. The client reports the knee is extremely painful to touch for the second time in 6 months. The healthcare provider prescribes colchicine and ibuprofen. Which instruction should the nurse include in the discharge teaching?
Decrease consumption of red meat and most seafood.
Support joints in an extended position while resting.
Massage joints to relax muscles and decrease pain.
Replace dietary table salt with salt substitutes.
Correct Answer: A. Decrease consumption of red meat and most seafood.
Explanation:
Clients with gout should limit foods high in purines, such as red meat, organ meats, and certain seafood (e.g., sardines, anchovies, shellfish), because purine metabolism produces uric acid, which can crystallize in joints and trigger painful inflammation. Reducing purine intake, increasing hydration, and avoiding alcohol—especially beer—help prevent gout flares. Colchicine and NSAIDs like ibuprofen reduce inflammation during acute attacks, but long-term management relies heavily on diet and lifestyle modification to lower uric acid levels and prevent recurrence.
The nurse is caring for a client who has been admitted with recurring migraine headaches. To assess the quality of the client's pain experienced from the migraine headache, which approach should the nurse use?
Ask the client to describe the pain.
Provide a numeric pain scale.
Identify effective pain relief measures.
Observe body language and movement.
Correct Answer: A. Ask the client to describe the pain.
Explanation:
Assessing the quality of pain involves having the client describe the characteristics of the pain in their own words—such as whether it is throbbing, sharp, dull, or burning. This subjective data helps the nurse understand the sensory experience and tailor interventions appropriately. While numeric pain scales (B) measure pain intensity, and observing behavior (D) provides clues about discomfort, the client’s verbal description is the most accurate and direct way to assess the quality of migraine pain.
A client who has asthma receives a new prescription for a corticosteroid inhaler. The client expresses concern about taking steroid medications. Which information should the nurse provide the client about the use of this maintenance inhaler?
Oral care is not required after each use of the inhaler.
Inhaled medications are easier to take than oral forms.
No weaning is required when stopping the use of this inhaler.
Systemic side effects are reduced when taken by inhalation.
Correct Answer: D. Systemic side effects are reduced when taken by inhalation.
Explanation:
Inhaled corticosteroids act directly in the airways, providing effective anti-inflammatory control for asthma with minimal systemic absorption, which significantly reduces the risk of adverse effects seen with oral or IV steroids. This makes them safer for long-term maintenance therapy. The nurse should also remind the client to rinse the mouth after each use to prevent oral candidiasis (thrush). Corticosteroid inhalers are not used for acute relief, and abrupt discontinuation without provider guidance can lead to loss of asthma control.
A client is admitted to the psychiatric department on an emergency commitment. The client's spouse asks the nurse, "What is going to happen to my spouse? Can I take my spouse home now?" Which information should the nurse provide?
Discharge can be completed after arrangements with the business office.
A psychiatric evaluation is required for continued hospitalization.
Emergency commitment extends to a maximum of 90 days.
Hospitalization is mandated until a mental health court hearing is held.
Correct Answer:
B. A psychiatric evaluation is required for continued hospitalization.
Explanation:
An emergency psychiatric commitment allows for temporary hospitalization of an individual who poses an immediate risk to themselves or others due to a mental health crisis. This type of commitment is short-term, typically lasting 24 to 72 hours, during which the client must undergo a comprehensive psychiatric evaluation. The purpose of this evaluation is to determine whether continued hospitalization or formal involuntary commitment is warranted.
A client who gave birth 48 hours ago has decided to bottle feed the infant. During the assessment, the nurse observes that both breasts are swollen, warm, and tender on palpation. Which instruction should the nurse provide?
Run warm water over breasts.
Express small amounts of milk from the breasts to relieve pressure.
Apply ice to the breasts for comfort.
Wear a loose-fitting bra during the day to prevent nipple irritation.
Correct Answer: C. Apply ice to the breasts for comfort.
Explanation:
Breast engorgement commonly occurs 2 to 5 days postpartum when milk production begins, even in mothers who choose not to breastfeed. The appropriate management for non-lactating mothers is to apply ice packs, wear a supportive, well-fitting bra continuously, and avoid breast stimulation such as expressing milk, warm showers, or nipple manipulation. These measures help suppress milk production and relieve discomfort.
Applying warm water (A) or expressing milk (B) stimulates lactation and worsens engorgement. A loose-fitting bra (D) fails to provide adequate support and may increase pain. The nurse should reinforce comfort measures and milk suppression techniques until engorgement resolves spontaneously within a few days.
A client who had a right total knee replacement two days ago is progressed to a soft diet. What food selection(s) should the nurse recommend to this client? Select all that apply.
Fried chicken and green salad.
Scrambled eggs and potatoes.
Pasta with a cream sauce.
Steamed rice and cooked squash.
Ice cream with nuts.
Pancakes with syrup.
Correct Answers:
B. Scrambled eggs and potatoes, C. Pasta with a cream sauce, D. Steamed rice and cooked squash, F. Pancakes with syrup.
Explanation:
B. Scrambled eggs and potatoes
Scrambled eggs and soft-cooked potatoes are ideal for a soft diet because they are easy to chew, swallow, and digest. Eggs provide protein to support tissue repair after surgery, while potatoes supply carbohydrates for energy. Both foods are gentle on the gastrointestinal tract and appropriate for postoperative recovery.
C. Pasta with a cream sauce
Pasta is smooth and soft in texture, making it suitable for a soft diet. The cream sauce provides calories and energy needed for healing while maintaining a palatable and easily digestible meal option. This selection ensures adequate nutrition without causing discomfort or strain during chewing.
D. Steamed rice and cooked squash
Steamed rice and well-cooked vegetables like squash are mild and easy to digest, which fits the requirements of a soft diet. These foods provide carbohydrates, vitamins, and fiber for recovery without irritating the digestive system. They also help maintain energy levels while promoting gentle digestion.
F. Pancakes with syrup
Pancakes are tender and simple to chew, providing a pleasant carbohydrate source for energy. When served with syrup, they offer additional calories, which are beneficial for clients recovering from surgery. This meal is easy to tolerate and suitable for clients transitioning to regular diets.
The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping, and aspiration pneumonia. Which is the priority nursing assessment that should be done before administering this medication?
Obtain and record the client's vital signs.
Ask the client about soft food preferences.
Determine which side of the body is weak.
Auscultate the client's breath sounds.
Correct Answer:
D. Auscultate the client's breath sounds.
Explanation:
The client’s symptoms — unilateral weakness, ptosis, mouth drooping, and aspiration pneumonia — indicate possible neurologic impairment affecting swallowing ability and airway protection, such as a stroke or neuromuscular disorder. Before giving an oral medication, the nurse must assess breath sounds to detect signs of aspiration, such as crackles, diminished air entry, or rhonchi, which suggest fluid or infection in the lungs. If breath sounds indicate aspiration or respiratory compromise, oral medications should be withheld, and alternative routes should be considered to prevent further aspiration and respiratory distress.
An adult client with a diagnosis of bipolar disorder arrives in an elated state on admission to the psychiatric unit. Which is the best room assignment the nurse can make for this client?
A room that contains very little furniture.
A room that has at least two other clients assigned to it.
A bright colored room located near the recreation room.
A quiet room away from the nurse's station.
Correct Answer:
A. A room that contains very little furniture.
Explanation:
A client experiencing mania (elated state) due to bipolar disorder often demonstrates hyperactivity, impulsivity, and poor judgment, which can lead to accidental injury or destruction of property. The best room assignment is one that contains minimal furniture and simple surroundings, reducing the risk of harm to the client and others while limiting external stimulation. This environment supports safety and helps decrease sensory overload, which can worsen manic symptoms.
Which intervention is best for the nurse to implement for a client who is experiencing severe toe pain as the result of acute gout?
Apply antiembolism stockings bilaterally.
Place a foot cradle under the linen.
Provide passive range of motion to the foot and toes.
Minimize calcium rich foods in diet.
Correct Answer:
B. Place a foot cradle under the linen.
Explanation:
During an acute gout attack, even the slightest touch or pressure on the affected joint—often the great toe—can cause excruciating pain due to severe inflammation and uric acid crystal deposition. The best nursing intervention is to place a foot cradle under the bed linen to keep sheets and blankets off the inflamed area, reducing discomfort and preventing unnecessary stimulation of pain receptors. This intervention provides comfort and allows healing without additional irritation.
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