Clinical Judgement Exam HESI Compass
Questions With Complete Answers
A client with deep vein thrombosis (DVT) is receiving a continuous intravenous
heparin infusion. The client now has tarry, black diarrhea and reports abdominal
pain. Which actions should the nurse implement? (Select all that apply.)
Monitor stools for presence of blood.
Auscultate bowel sounds in all quadrants.
Review last partial thromboplastin time results.
Prepare to administer warfarin.
Assess characteristics of pain. - ANSWER key words abdominal pain- auscultate
for bowel sounds too(missed this)
Monitor stools for presence of blood.
Auscultate bowel sounds in all quadrants.
Review last partial thromboplastin time results.
Assess characteristics of pain.
When is it most important for the nurse to assess a pregnant client's deep
tendon reflexes (DTRs)? - ANSWER Client has elevated BP
SBP >140 or DBP >90 =sign of preeclampsia (protein in urine and edema of
hands & feet are also a key features)
constant alarm & low o2 from ventilator indicates? - ANSWER malfunction. First
action is to begin manual ventilation immediately
The nurse has completed the diet teaching of a client who is being discharged
following treatment of a leg wound. A high protein diet is encouraged to promote
wound healing. Which lunch choice by the client indicates that the teaching was
effective? - ANSWER tuna sandwich w chips & ice cream
In a high protein diet, a lunch with fish and dairy contains the highest amount of
protein. For instance, four ounces of tuna contains 11 grams of protein, and ice
cream 5 grams of protein per cup.
At 40-weeks gestation, a client who is in active labor is lying in a supine position
and tells the nurse that she has finally found a comfortable position. What action
should the nurse take? - ANSWER Place a wedge under the client's right hip
,hypotension from pressure on the vena cava due to the weight of the fetus-puts
full term client at risk
-Placing this way will displace the fetus and relieve pressure on the vena cava
The nurse is assessing a client with a closed head injury sustained in a motor
vehicle collision. Which finding indicates the lowest level of neurologic
functioning? - ANSWER decerebrate posturing during position changes
-The lowest level of neurological functioning is characterized by decerebrate
posturing (abnormal extension). Posturing (decorticate or decerebrate) is not
considered a purposeful response to pain.
-As neurological functioning deteriorates, the client will progress from
localization of a tactile stimulus to withdrawal from painful stimuli, followed by
decorticate posturing in response to the stimuli, before finally exhibiting
decerebrate posturing.
A client with delusions tells the nurse, "You aren't doing your job. Go get those
people over there and shoot them before they get me." Which statement is the
nurse's best response?
a) no one will hurt you
b) you seem quite frightened rn - ANSWER b) you seem quite frightened
A client with delusions firmly holds false beliefs to be true, and it is best to
acknowledge feelings related to the delusion. Reassuring statements such as,
"You will be alright" are not effective for such clients.
An antacid is prescribed for a client with gastroesophageal reflux (GERD). The
client asks the nurse, "How does this help my GERD?" Which is the best
response by the nurse?
a)antacids decrease prod of gastric secretions
b)antacids will neutralize the acid in stomach - ANSWER b)antacids will
neutralize the acid in stomach
Antacids neutralize hydrochloric acid in the stomach reducing the heartburn
associated with gastroesophageal reflux disease (GERD).
What instruction should the nurse provide the parents of a 3-year-old boy with a
BMI-for-age at the 97th percentile? - ANSWER yo child is overweight for his age
& size-help him select healthy foods
Children with a BMI-for-age at or above the 95th percentile are considered
overweight, and at risk for obesity and all the associated health problems. The
nurse should offer recommendations for healthy eating and exercise.
, When should the nurse conduct an Allen's test? - ANSWER The Allen's test
should be performed prior to puncturing the radial artery to obtain a blood gas
specimen to determine patency of the ulnar artery in the selected extremity.
To perform an Allen's test:
1) The client's hand is formed into a fist while the nurse compresses the ulnar
artery.
2) Compression continues while the fist is opened.
3) If blood perfusion through the radial artery is adequate, the hand should flush
and resume its normal pinkish coloration.
A client with bleeding esophageal varices receives vasopressin IV. Which
should the nurse monitor for during the IV infusion of this medication? -
ANSWER chest pain & dysrhythmia
In large doses, vasopressin may produce increased blood pressure, coronary
insufficiency, myocardial ischemia or infarction, and dysrhythmia.
-vasopressin constricts blood vessels= HTN adverse effect
The wife of a client diagnosed with Parkinson's disease tells the nurse that her
husband is having trouble swallowing and she is afraid he is going to choke.
Which intervention should the nurse implement? - ANSWER teach wife to thicken
all liquids & serve semi-solid foods
Dysphagia is usually a chronic problem for the client with Parkinson's disease. A
semi-solid diet with thick liquids is easier to swallow than solid foods.
Several clients on a busy antepartum unit are scheduled for procedures that
require informed consent. Which situation should the nurse explore further
before witnessing the client's signature on the consent form? - ANSWER OB
explained a procedure that a neurologist will perform
The individual who is ultimately responsible for the procedure should provide
the information necessary for informed consent, so when an obstetrician
explains the procedure scheduled to be performed by a neurologist this should
be explored further by the nurse before witnessing the client's signature.
A client with gestational diabetes is being induced for labor. Which assessment
is most important for the nurse to perform prior to increasing the oxytocin rate?
Vaginal exam.
Blood pressure.
Contraction pattern.
Fingerstick glucose. - ANSWER Contraction pattern.
Before increasing the rate of the oxytocin infusion, it is most important for the
nurse to determine the frequency and pattern of uterine contractions.
Questions With Complete Answers
A client with deep vein thrombosis (DVT) is receiving a continuous intravenous
heparin infusion. The client now has tarry, black diarrhea and reports abdominal
pain. Which actions should the nurse implement? (Select all that apply.)
Monitor stools for presence of blood.
Auscultate bowel sounds in all quadrants.
Review last partial thromboplastin time results.
Prepare to administer warfarin.
Assess characteristics of pain. - ANSWER key words abdominal pain- auscultate
for bowel sounds too(missed this)
Monitor stools for presence of blood.
Auscultate bowel sounds in all quadrants.
Review last partial thromboplastin time results.
Assess characteristics of pain.
When is it most important for the nurse to assess a pregnant client's deep
tendon reflexes (DTRs)? - ANSWER Client has elevated BP
SBP >140 or DBP >90 =sign of preeclampsia (protein in urine and edema of
hands & feet are also a key features)
constant alarm & low o2 from ventilator indicates? - ANSWER malfunction. First
action is to begin manual ventilation immediately
The nurse has completed the diet teaching of a client who is being discharged
following treatment of a leg wound. A high protein diet is encouraged to promote
wound healing. Which lunch choice by the client indicates that the teaching was
effective? - ANSWER tuna sandwich w chips & ice cream
In a high protein diet, a lunch with fish and dairy contains the highest amount of
protein. For instance, four ounces of tuna contains 11 grams of protein, and ice
cream 5 grams of protein per cup.
At 40-weeks gestation, a client who is in active labor is lying in a supine position
and tells the nurse that she has finally found a comfortable position. What action
should the nurse take? - ANSWER Place a wedge under the client's right hip
,hypotension from pressure on the vena cava due to the weight of the fetus-puts
full term client at risk
-Placing this way will displace the fetus and relieve pressure on the vena cava
The nurse is assessing a client with a closed head injury sustained in a motor
vehicle collision. Which finding indicates the lowest level of neurologic
functioning? - ANSWER decerebrate posturing during position changes
-The lowest level of neurological functioning is characterized by decerebrate
posturing (abnormal extension). Posturing (decorticate or decerebrate) is not
considered a purposeful response to pain.
-As neurological functioning deteriorates, the client will progress from
localization of a tactile stimulus to withdrawal from painful stimuli, followed by
decorticate posturing in response to the stimuli, before finally exhibiting
decerebrate posturing.
A client with delusions tells the nurse, "You aren't doing your job. Go get those
people over there and shoot them before they get me." Which statement is the
nurse's best response?
a) no one will hurt you
b) you seem quite frightened rn - ANSWER b) you seem quite frightened
A client with delusions firmly holds false beliefs to be true, and it is best to
acknowledge feelings related to the delusion. Reassuring statements such as,
"You will be alright" are not effective for such clients.
An antacid is prescribed for a client with gastroesophageal reflux (GERD). The
client asks the nurse, "How does this help my GERD?" Which is the best
response by the nurse?
a)antacids decrease prod of gastric secretions
b)antacids will neutralize the acid in stomach - ANSWER b)antacids will
neutralize the acid in stomach
Antacids neutralize hydrochloric acid in the stomach reducing the heartburn
associated with gastroesophageal reflux disease (GERD).
What instruction should the nurse provide the parents of a 3-year-old boy with a
BMI-for-age at the 97th percentile? - ANSWER yo child is overweight for his age
& size-help him select healthy foods
Children with a BMI-for-age at or above the 95th percentile are considered
overweight, and at risk for obesity and all the associated health problems. The
nurse should offer recommendations for healthy eating and exercise.
, When should the nurse conduct an Allen's test? - ANSWER The Allen's test
should be performed prior to puncturing the radial artery to obtain a blood gas
specimen to determine patency of the ulnar artery in the selected extremity.
To perform an Allen's test:
1) The client's hand is formed into a fist while the nurse compresses the ulnar
artery.
2) Compression continues while the fist is opened.
3) If blood perfusion through the radial artery is adequate, the hand should flush
and resume its normal pinkish coloration.
A client with bleeding esophageal varices receives vasopressin IV. Which
should the nurse monitor for during the IV infusion of this medication? -
ANSWER chest pain & dysrhythmia
In large doses, vasopressin may produce increased blood pressure, coronary
insufficiency, myocardial ischemia or infarction, and dysrhythmia.
-vasopressin constricts blood vessels= HTN adverse effect
The wife of a client diagnosed with Parkinson's disease tells the nurse that her
husband is having trouble swallowing and she is afraid he is going to choke.
Which intervention should the nurse implement? - ANSWER teach wife to thicken
all liquids & serve semi-solid foods
Dysphagia is usually a chronic problem for the client with Parkinson's disease. A
semi-solid diet with thick liquids is easier to swallow than solid foods.
Several clients on a busy antepartum unit are scheduled for procedures that
require informed consent. Which situation should the nurse explore further
before witnessing the client's signature on the consent form? - ANSWER OB
explained a procedure that a neurologist will perform
The individual who is ultimately responsible for the procedure should provide
the information necessary for informed consent, so when an obstetrician
explains the procedure scheduled to be performed by a neurologist this should
be explored further by the nurse before witnessing the client's signature.
A client with gestational diabetes is being induced for labor. Which assessment
is most important for the nurse to perform prior to increasing the oxytocin rate?
Vaginal exam.
Blood pressure.
Contraction pattern.
Fingerstick glucose. - ANSWER Contraction pattern.
Before increasing the rate of the oxytocin infusion, it is most important for the
nurse to determine the frequency and pattern of uterine contractions.
