EXIT HESI COMPREHENSIVE B EVOLVE
EXAM SCRIPT 2026 COMPLETE QUESTIONS
AND SOLUTIONS GUARANTEED PASS
●● When caring for a postsurgical client who has undergone multiple
blood transfusions, which serum laboratory finding is of most concern to
the nurse?
Answer: B.Potassium level, 5.5 mEq/L
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?
Answer: A. Hepatitis B
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)?
Answer: B.Obtain a fingerstick blood glucose level.
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.)
Answer: B. Complete the National Institute of Health Stroke Scale
(NIHSS).
C. Assess the client for signs of bleeding during and after the infusion.
E. Initiate multidisciplinary consult for potential rehabilitation.
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?
Answer: B. Fetal heart rate, 100 beats/min
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?
Answer: C. Position in a high Fowler's position with the legs down.
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?
Answer: A. Administer a dose of benztropine mesylate (Cogentin) PRN.
, 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?
Answer: B. Ten-month-old who cannot sit without support
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?
Answer: C .Provide a low-residue diet.
Rationale:
EXAM SCRIPT 2026 COMPLETE QUESTIONS
AND SOLUTIONS GUARANTEED PASS
●● When caring for a postsurgical client who has undergone multiple
blood transfusions, which serum laboratory finding is of most concern to
the nurse?
Answer: B.Potassium level, 5.5 mEq/L
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?
Answer: A. Hepatitis B
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)?
Answer: B.Obtain a fingerstick blood glucose level.
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.)
Answer: B. Complete the National Institute of Health Stroke Scale
(NIHSS).
C. Assess the client for signs of bleeding during and after the infusion.
E. Initiate multidisciplinary consult for potential rehabilitation.
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?
Answer: B. Fetal heart rate, 100 beats/min
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?
Answer: C. Position in a high Fowler's position with the legs down.
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?
Answer: A. Administer a dose of benztropine mesylate (Cogentin) PRN.
, 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?
Answer: B. Ten-month-old who cannot sit without support
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?
Answer: C .Provide a low-residue diet.
Rationale:
