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BSN 395 Summer 2026 Hesi Compass Exit B Proctored Exam
Total Questions : 130
Showing 10 questions, Sign in for moreA 6-month-old infant is admitted to the hospital with diarrhea. The parent is feeding the infant a bottle of tap water and tells the nurse that the baby has taken three 8-ounce (240 mL) bottles of water in the last 4 hours. Which laboratory finding is most important for the nurse to monitor?
Which is the best method a nurse can teach a mother of an infant to minimize the occurrence of a diaper rash?
An older adult client with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. Which intervention(s) should the nurse include in this client's plan of care (POC)? Select all that apply.
The nurse removes the evening meal tray from a client who has severe obstructive sleep apnea (OSA) and is begining preparations for evening care. Which intervention is most important for the nurse to implement before leaving the client?
The nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?
- The client is a 26-year-old female who fell from an apartment balcony.
- She was transported to the hospital via ambulance.
Patient Data
The client enters the emergency department (ED) on a stretcher and is met in the trauma bay by the nurse.
For the primary survey, which 2 things should the nurse do first?
- The client is a 26-year-old female who fell from an apartment balcony.
- She was transported to the hospital via ambulance.
1030
- Cervical collar placed to stabilize the spine.
Patient Data
The nurse inspects the airway. There is no visible trauma, and the airway appears to be patent.
Which other assessment item(s) are included in the primary survey? Select all that apply.
The client is a 26-year-old female who fell from an apartment balcony. She was transported to the hospital via ambulance.
1030
- Cervical collar placed to stabilize the spine.
- Pupils are equal and reactive to light. The client opens her eyes to verbal stimuli. She has an abrasion to the left forehead, and her right arm is swollen and appears fractured.
Initial
- Temperature: 96° F (35.6° C) orally
- Heart rate: 106 beats/minute
- Respirations: 14 breaths/minute
- Blood pressure: 83/41 mm Hg
- Oxygen saturation: 82% on room air
Patient Data
The nurse is reviewing the assessment findings.
For each body system, click to specify the potential nursing intervention that would be appropriate for the care of the client. Each body system may support more than one potential nursing intervention. Each category must have at least one response option selected.
|
Body System |
Nurse's Notes |
Intervention |
|
Respiratory |
Respiratory rate of 14 breaths/minute Oxygen saturation 82% on room air |
dropdown
|
|
Cardiovascular |
Heart rate 106 beats/minute Blood pressure 83/41 mm Hg |
dropdown
|
Explanation
Brief Introduction:
Initial trauma management mandates immediate stabilization of the respiratory and cardiovascular systems to preserve vital organ tissue perfusion. Severe hypoxemia and profound hypotension following a high fall indicate life threatening physiological compromise. Prioritizing airway protection and aggressive intravascular fluid resuscitation prevents secondary hypoxic injuries and treats underlying traumatic shock states.
Rationale: Respiratory Interventions
- Apply oxygen via nasal canula: This option is incorrect because a nasal cannula is a low flow oxygen delivery device that can only provide an oxygen fraction up to forty four percent. An oxygen saturation of eighty two percent signifies profound hypoxemia that requires high flow oxygen or advanced airway management rather than low flow therapy.
- Prepare for immediate intubation: This option is correct because the client has an extremely low oxygen saturation of eighty two percent on room air alongside a traumatic brain injury risk indicated by opening eyes only to verbal stimuli. Immediate endotracheal intubation provides definitive airway protection, corrects severe hypoxemia, and prevents respiratory failure.
Cardiovascular Interventions
- Administer IV 0.9% saline: This option is correct because the client's blood pressure of eighty three over forty one and heart rate of one hundred six indicate severe hypotension and compensatory tachycardia from traumatic shock. Administering an intravenous isotonic crystalloid bolus is critical to expand vascular volume and restore vital organ perfusion.
- Administer sublingual nifedipine: This option is incorrect because nifedipine is a calcium channel blocker used to lower blood pressure. Giving a vasodilating agent to a trauma client who is already profoundly hypotensive with a blood pressure of eighty three over forty one would cause catastrophic cardiovascular collapse.
The client is a 26-year-old female who fell from an apartment balcony. She was transported to the hospital via ambulance.
Initial
- Temperature: 96° F (35.6° C) orally
- Heart rate: 106 beats/minute
- Respirations: 14 breaths/minute
- Blood pressure: 83/41 mm Hg
- Oxygen saturation: 82% on room air
1030
- Cervical collar placed to stabilize the spine.
- Pupils are equal and reactive to light. The client opens her eyes to verbal stimuli. She has an abrasion to the left forehead, and her right arm is swollen and appears fractured.
1030
- Administer oxygen 5 L/minute via simple facemask
- Vital signs every 1 hour
- X-ray of the right arm and cervical spine
- Place 2 large bore peripheral IV's (PIVS) • Computed tomography (CT) scan of the head
- Give 1 liter bolus of 0.9% sodium chloride IV fluids once
- Cleanse wound with sterile saline, pat dry, apply bacitracin topically to lacerations every 12 hours, foam dressing
Patient Data
Highlight the 3 prescriptions that should be completed first.
- The client is a 26-year-old female who fell from an apartment balcony.
- She was transported to the hospital via ambulance.
Initial
- Temperature: 96° F (35.6° C) orally
- Heart rate: 106 beats/minute
- Respirations: 14 breaths/minute
- Blood pressure: 83/41 mm Hg
- Oxygen saturation: 82% on room air
1030
- Cervical collar placed to stabilize the spine.
- Pupils are equal and reactive to light. The client opens her eyes to verbal stimuli. She has an abrasion to the left forehead, and her right arm is swollen and appears fractured.
1030
- Administer oxygen 5 L/minute via simple facemask
- Vital signs every 1 hour
- X-ray of the right arm and cervical spine
- Place 2 large bore peripheral IV's (PIVS) • Computed tomography (CT) scan of the head
- Give 1 liter bolus of 0.9% sodium chloride IV fluids once
- Cleanse wound with sterile saline, pat dry, apply bacitracin topically to lacerations every 12 hours, foam dressing
Patient Data
The nurse collects blood from the client during peripheral IV (PIV) line placement.
Which laboratory specimens would the nurse expect for the healthcare provider (HCP) to prescribe? Select all that apply.
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