EXIT HESI Comprehensive B Evolve Practice
Questions | RN NCLEX Review + Answer Key &
Rationales | Priority Nursing, Delegation,
Med-Surg, Maternity, Pediatric, Psychiatric,
Pharmacology
The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral
tube feedings. Which task performed by the UAP requires immediate intervention by the nurse?
A.Suctions oral secretions from mouth
B.Positions head of bed flat when changing sheets
C.Takes temperature using the axillary method
D.Keeps head of bed elevated at 30 degrees - ---correct answer ---B
Rationale:
Positioning the head of the bed flat when enteral feedings are in progress puts the client at risk
for aspiration (B). The others are all acceptable tasks performed by the UAP (A, C, and D).
When caring for a postsurgical client who has undergone multiple blood transfusions, which
serum laboratory finding is of most concern to the nurse?
A.Sodium level, 137 mEq/L
B.Potassium level, 5.5 mEq/L
C.Blood urea nitrogen (BUN) level, 18 mg/dL
D.Calcium level, 10 mEq/L - ---correct answer ---B
Rationale:
Multiple blood transfusions are a risk factor for hyperkalemia. A serum potassium level higher
than 5.0 mEq/L indicates hyperkalemia (B). The others are normal findings (A, C, and D).
,Which vaccination should the nurse administer to a newborn?
A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
D.Meningococcal vaccine - ---correct answer ---A
Rationale:
The hepatitis B vaccination should be given to all newborns before hospital discharge (A). HPV
is not recommended until adolescence (B). Varicella immunization begins at 12 months (C).
Meningococcal vaccine is administered beginning at 2 years (D).
The nurse is caring for a client on the medical unit. Which task can be delegated to unlicensed
assistive personnel (UAP)?
A.Assess the need to change a central line dressing.
B.Obtain a fingerstick blood glucose level.
C.Answer a family member's questions about the client's plan of care.
D.Teach the client side effects to report related to the current medication regimen. - ---
correct answer ---B
Rationale:
Obtaining a fingerstick blood glucose level is a simple treatment and is an appropriate skill for
UAP to perform (B). (A, C, and D) are skills that cannot be delegated to UAP.
The nurse is caring for a client with an ischemic stroke who has a prescription for tissue
plasminogen activator (t-PA) IV. Which action(s) should the nurse expect to implement? (Select
all that apply.)
A.Administer aspirin with tissue plasminogen activator (t-PA).
B.Complete the National Institute of Health Stroke Scale (NIHSS).
C.Assess the client for signs of bleeding during and after the infusion.
D.Start t-PA within 6 hours after the onset of stroke symptoms.
,E.Initiate multidisciplinary consult for potential rehabilitation. - ---correct answer --
-B,C,E
Rationale:
Neurologic assessment, including the NIHSS, is indicated for the client receiving t-PA. This
includes close monitoring for bleeding during and after the infusion; if bleeding or other signs of
neurologic impairment occur, the infusion should be stopped (B, C, and E). Aspirin is
contraindicated with t-PA because it increases the risk for bleeding (A). The administration of t-
PA within 6 hours of symptoms is concurrent with a diagnosis of a myocardial infarction and
within 4.5 hours of symptoms is concurrent for a stroke (D).
When caring for a client in labor, which finding is most important to report to the primary health
care provider?
A.Maternal heart rate, 90 beats/min.
B.Fetal heart rate, 100 beats/min
C.Maternal blood pressure, 140/86 mm Hg
D.Maternal temperature, 100.0° F - ---correct answer ---B
Rationale:
A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress (B) because the average
FHR at term is 140 beats/min and the normal range is 110 to beats/min 160. The others (A, C,
and D) are normal findings for a woman in labor.
The nurse is caring for a client with heart failure who develops respiratory distress and coughs up
pink frothy sputum. Which action should the nurse take first?
A.Draw arterial blood gases.
B.Notify the primary health care provider.
C.Position in a high Fowler's position with the legs down.
D.Obtain a chest X-ray. - ---correct answer ---C
Rationale:
Positioning the patient in a high Fowler's position with dangling feet will decrease further venous
return to the left ventricle (C). The other actions should be performed after the change in position
(A, B, and D).
, A client who is prescribed chlorpromazine HCl (Thorazine) for schizophrenia develops rigidity,
a shuffling gait, and tremors. Which action by the nurse is most important?A.Administer a dose
of benztropine mesylate (Cogentin) PRN.
B.Determine if the client has increased photosensitivity.
C.Provide comfort measures for sore muscles.
D.Assess the client for visual and auditory hallucinations. - ---correct answer ---A
Rationale:
Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and masklike face are
extrapyramidal side effects associated with Thorazine. It is most important for the nurse to
administer an anticholinergic such as Cogentin to reverse these effects (A). The others (B, C, D)
may be appropriate interventions but are not as urgent as (A).
A nurse is interviewing a mother during a well-child visit. Which finding would alert the nurse to
continue further assessment of the infant?
A.Two-month-old who is unable to roll from back to abdomen
B.Ten-month-old who cannot sit without support
C.Nine-month-old who cries when his mother leaves the room
D.Eight-month-old who has not yet begun to speak words - ---correct answer ---B
Rationale:
As a developmental milestone, infants should sit unsupported by 8 months (B). The milestone of
rolling over is achieved at 5 to 6 months for most infants (A). Stranger anxiety is common from
7 to 9 months (C). Speaking a few words is expected at about 12 months (D).
Which intervention should be included in the plan of care for a client admitted to the hospital
with ulcerative colitis?
A.Administer stool softeners.
B.Place the client on fluid restriction.
C.Provide a low-residue diet.
D.Add a milk product to each meal. - ---correct answer ---C
Questions | RN NCLEX Review + Answer Key &
Rationales | Priority Nursing, Delegation,
Med-Surg, Maternity, Pediatric, Psychiatric,
Pharmacology
The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral
tube feedings. Which task performed by the UAP requires immediate intervention by the nurse?
A.Suctions oral secretions from mouth
B.Positions head of bed flat when changing sheets
C.Takes temperature using the axillary method
D.Keeps head of bed elevated at 30 degrees - ---correct answer ---B
Rationale:
Positioning the head of the bed flat when enteral feedings are in progress puts the client at risk
for aspiration (B). The others are all acceptable tasks performed by the UAP (A, C, and D).
When caring for a postsurgical client who has undergone multiple blood transfusions, which
serum laboratory finding is of most concern to the nurse?
A.Sodium level, 137 mEq/L
B.Potassium level, 5.5 mEq/L
C.Blood urea nitrogen (BUN) level, 18 mg/dL
D.Calcium level, 10 mEq/L - ---correct answer ---B
Rationale:
Multiple blood transfusions are a risk factor for hyperkalemia. A serum potassium level higher
than 5.0 mEq/L indicates hyperkalemia (B). The others are normal findings (A, C, and D).
,Which vaccination should the nurse administer to a newborn?
A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
D.Meningococcal vaccine - ---correct answer ---A
Rationale:
The hepatitis B vaccination should be given to all newborns before hospital discharge (A). HPV
is not recommended until adolescence (B). Varicella immunization begins at 12 months (C).
Meningococcal vaccine is administered beginning at 2 years (D).
The nurse is caring for a client on the medical unit. Which task can be delegated to unlicensed
assistive personnel (UAP)?
A.Assess the need to change a central line dressing.
B.Obtain a fingerstick blood glucose level.
C.Answer a family member's questions about the client's plan of care.
D.Teach the client side effects to report related to the current medication regimen. - ---
correct answer ---B
Rationale:
Obtaining a fingerstick blood glucose level is a simple treatment and is an appropriate skill for
UAP to perform (B). (A, C, and D) are skills that cannot be delegated to UAP.
The nurse is caring for a client with an ischemic stroke who has a prescription for tissue
plasminogen activator (t-PA) IV. Which action(s) should the nurse expect to implement? (Select
all that apply.)
A.Administer aspirin with tissue plasminogen activator (t-PA).
B.Complete the National Institute of Health Stroke Scale (NIHSS).
C.Assess the client for signs of bleeding during and after the infusion.
D.Start t-PA within 6 hours after the onset of stroke symptoms.
,E.Initiate multidisciplinary consult for potential rehabilitation. - ---correct answer --
-B,C,E
Rationale:
Neurologic assessment, including the NIHSS, is indicated for the client receiving t-PA. This
includes close monitoring for bleeding during and after the infusion; if bleeding or other signs of
neurologic impairment occur, the infusion should be stopped (B, C, and E). Aspirin is
contraindicated with t-PA because it increases the risk for bleeding (A). The administration of t-
PA within 6 hours of symptoms is concurrent with a diagnosis of a myocardial infarction and
within 4.5 hours of symptoms is concurrent for a stroke (D).
When caring for a client in labor, which finding is most important to report to the primary health
care provider?
A.Maternal heart rate, 90 beats/min.
B.Fetal heart rate, 100 beats/min
C.Maternal blood pressure, 140/86 mm Hg
D.Maternal temperature, 100.0° F - ---correct answer ---B
Rationale:
A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress (B) because the average
FHR at term is 140 beats/min and the normal range is 110 to beats/min 160. The others (A, C,
and D) are normal findings for a woman in labor.
The nurse is caring for a client with heart failure who develops respiratory distress and coughs up
pink frothy sputum. Which action should the nurse take first?
A.Draw arterial blood gases.
B.Notify the primary health care provider.
C.Position in a high Fowler's position with the legs down.
D.Obtain a chest X-ray. - ---correct answer ---C
Rationale:
Positioning the patient in a high Fowler's position with dangling feet will decrease further venous
return to the left ventricle (C). The other actions should be performed after the change in position
(A, B, and D).
, A client who is prescribed chlorpromazine HCl (Thorazine) for schizophrenia develops rigidity,
a shuffling gait, and tremors. Which action by the nurse is most important?A.Administer a dose
of benztropine mesylate (Cogentin) PRN.
B.Determine if the client has increased photosensitivity.
C.Provide comfort measures for sore muscles.
D.Assess the client for visual and auditory hallucinations. - ---correct answer ---A
Rationale:
Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and masklike face are
extrapyramidal side effects associated with Thorazine. It is most important for the nurse to
administer an anticholinergic such as Cogentin to reverse these effects (A). The others (B, C, D)
may be appropriate interventions but are not as urgent as (A).
A nurse is interviewing a mother during a well-child visit. Which finding would alert the nurse to
continue further assessment of the infant?
A.Two-month-old who is unable to roll from back to abdomen
B.Ten-month-old who cannot sit without support
C.Nine-month-old who cries when his mother leaves the room
D.Eight-month-old who has not yet begun to speak words - ---correct answer ---B
Rationale:
As a developmental milestone, infants should sit unsupported by 8 months (B). The milestone of
rolling over is achieved at 5 to 6 months for most infants (A). Stranger anxiety is common from
7 to 9 months (C). Speaking a few words is expected at about 12 months (D).
Which intervention should be included in the plan of care for a client admitted to the hospital
with ulcerative colitis?
A.Administer stool softeners.
B.Place the client on fluid restriction.
C.Provide a low-residue diet.
D.Add a milk product to each meal. - ---correct answer ---C
