EXIT HESI COMPREHENSIVE B EVOLVE
EXAMINATION TEST 2026 FULL QUESTIONS
AND SOLUTIONS GRADED A+
●● 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.
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.
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..
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..
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.
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..
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..
Answer: A
EXAMINATION TEST 2026 FULL QUESTIONS
AND SOLUTIONS GRADED A+
●● 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.
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.
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..
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..
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.
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..
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..
Answer: A
