EXIT HESI COMPREHENSIVE B EVOLVE PRACTICE QUESTIONS/EXIT HESI
COMPREHENSIVE B EVOLVE PRACTICE QUESTIONS AND ANSWERS LATEST 2025/2026
UPDATE
Question 1
The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral
tube feedings. Which task performed by the Unlicensed Assistive Personnel (UAP) requires
immediate intervention by the nurse?
A) Suctioning oral secretions from the mouth with a Yankauer
B) Positioning the head of the bed flat while changing the bottom sheets
C) Taking the client's temperature using the axillary method
D) Keeping the head of the bed elevated at 30 degrees during the feeding
E) Documenting the amount of water used for a flush
Correct Answer: B) Positions head of bed flat when changing sheets
Rationale: Positioning the head of the bed flat while enteral feedings are in progress or
immediately after significantly increases the risk of aspiration and subsequent pneumonia.
The nurse must ensure the HOB remains elevated at least 30 to 45 degrees. Suctioning oral
secretions and taking axillary temperatures are within the UAP’s scope of practice.
Question 2
A postsurgical client has received multiple units of packed red blood cells. Which laboratory
finding should the nurse prioritize for immediate reporting to the healthcare provider?
A) Serum Sodium level of 137 mEq/L
B) Serum Potassium level of 5.5 mEq/L
C) Blood Urea Nitrogen (BUN) level of 18 mg/dL
D) Serum Calcium level of 10 mg/dL
E) Hemoglobin level of 11 g/dL
Correct Answer: B) Potassium level, 5.5 mEq/L
Rationale: Stored blood undergoes hemolysis over time, which releases potassium into the
plasma. Multiple blood transfusions are a known risk factor for hyperkalemia. A potassium
level above 5.0 mEq/L is a critical finding that can lead to life-threatening cardiac
arrhythmias.
Question 3
Which vaccination is a priority for the nurse to administer to a newborn prior to hospital
discharge?
A) Hepatitis B
B) Human Papillomavirus (HPV)
C) Varicella
D) Meningococcal vaccine
E) Rotavirus
Correct Answer: A) Hepatitis B
Rationale: The Hepatitis B vaccine is the only immunization recommended at birth. HPV is
, 2
typically given during adolescence, Varicella at 12 months, and Meningococcal starting at
age 2 or later depending on risk factors.
Question 4
The nurse is managing a busy medical unit. Which task is most appropriate to delegate to the
Unlicensed Assistive Personnel (UAP)?
A) Assessing the integrity of a central line dressing
B) Obtaining a fingerstick blood glucose level
C) Explaining the plan of care to a concerned family member
D) Teaching a client about the side effects of new medications
E) Evaluating the effectiveness of an incentive spirometer
Correct Answer: B) Obtain a fingerstick blood glucose level.
Rationale: Obtaining a fingerstick glucose is a routine technical task that can be delegated
to a trained UAP. Assessment, teaching, evaluation, and discussing the medical plan of care
require the clinical judgment and specialized knowledge of a licensed nurse.
Question 5
A client with an ischemic stroke is receiving tissue plasminogen activator (t-PA) IV. Which
interventions should the nurse include in the plan of care? (Select all that apply.)
A) Administer 325 mg of Aspirin concurrently with the t-PA
B) Complete the National Institute of Health Stroke Scale (NIHSS)
C) Monitor closely for signs of internal or external bleeding
D) Administer the t-PA within 6 hours of symptom onset
E) Initiate a multidisciplinary consult for physical and occupational therapy
Correct Answer: B, C, E) Complete the National Institute of Health Stroke Scale (NIHSS);
Assess the client for signs of bleeding during and after the infusion; Initiate
multidisciplinary consult for potential rehabilitation.
Rationale: NIHSS provides a baseline and ongoing neurological assessment. Bleeding is the
primary complication of fibrinolytic therapy. Multidisciplinary rehab is essential for stroke
recovery. Aspirin is contraindicated during the first 24 hours of t-PA to prevent
hemorrhage. For stroke, t-PA must be given within 3 to 4.5 hours of symptom onset.
Question 6
When monitoring a client in active labor, which finding requires the most immediate notification
to the primary health care provider?
A) Maternal heart rate of 90 beats/min
B) Fetal heart rate of 100 beats/min
C) Maternal blood pressure of 140/86 mm Hg
D) Maternal temperature of 100.0° F
E) Contractions occurring every 3 minutes
Correct Answer: B) Fetal heart rate, 100 beats/min
, 3
Rationale: The normal fetal heart rate range is 110 to 160 beats/min. A rate of 100 beats/min
constitutes fetal bradycardia and may indicate fetal distress/hypoxia. The other vital signs
are within normal or expected limits for a client in labor.
Question 7
A client with heart failure develops acute respiratory distress and begins coughing up pink,
frothy sputum. Which nursing action is the priority?
A) Draw arterial blood gases (ABGs)
B) Notify the primary health care provider
C) Position the client in high Fowler’s with legs dangling
D) Obtain a portable chest X-ray
E) Auscultate the lungs for crackles
Correct Answer: C) Position in a high Fowler's position with the legs down.
Rationale: Pink frothy sputum is a hallmark of acute pulmonary edema. Positioning the
patient upright with the legs down (dangling) immediately decreases venous return
(preload) to the heart, which helps relieve pulmonary congestion. Other actions are
necessary but follow immediate positioning.
Question 8
A client prescribed Chlorpromazine HCl (Thorazine) for schizophrenia develops a shuffling gait,
tremors, and muscle rigidity. Which medication should the nurse expect to administer?
A) Benztropine mesylate (Cogentin)
B) Haloperidol (Haldol)
C) Lorazepam (Ativan)
D) Fluoxetine (Prozac)
E) Quetiapine (Seroquel)
Correct Answer: A) Administer a dose of benztropine mesylate (Cogentin) PRN.
Rationale: Shuffling gait, tremors, and rigidity are extrapyramidal side effects (EPS) or
pseudoparkinsonism caused by typical antipsychotics like Thorazine. Cogentin is an
anticholinergic used to reverse these side effects.
Question 9
During a well-child visit, which developmental finding in an infant should the nurse report for
further evaluation?
A) A two-month-old who cannot roll from back to stomach
B) A ten-month-old who cannot sit without support
C) A nine-month-old who cries when the parent leaves the room
D) An eight-month-old who has not yet spoken their first word
E) A six-month-old who reaches for a toy
Correct Answer: B) Ten-month-old who cannot sit without support
Rationale: Infants should be able to sit unsupported by 8 months of age. Rolling over occurs
, 4
by 5–6 months. Stranger anxiety (crying when the parent leaves) is normal between 7–9
months. The first words are not expected until approximately 12 months.
Question 10
Which dietary instruction is essential for a client hospitalized with an acute exacerbation of
ulcerative colitis?
A) Increase intake of raw fruits and vegetables
B) Follow a strict fluid restriction of 1 liter
C) Maintain a low-residue diet
D) Add whole milk to every meal
E) Eat high-fiber bran muffins for breakfast
Correct Answer: C) Provide a low-residue diet.
Rationale: A low-residue (low-fiber) diet reduces the amount of undigested food moving
through the colon, which helps decrease the frequency of diarrhea and provides "bowel
rest" during an acute flare of ulcerative colitis.
Question 11
The nurse is monitoring a client with deep vein thrombosis (DVT) on a continuous IV heparin
infusion. The current aPTT is 120 seconds. Which action is most appropriate?
A) Increase the infusion rate per the hospital's nomogram
B) Administer Vitamin K intramuscularly
C) Continue the infusion at the same rate and re-check in 4 hours
D) Stop the heparin drip and prepare to administer protamine sulfate
E) Switch the patient to oral Warfarin immediately
Correct Answer: D) Stop the heparin drip and prepare to administer protamine sulfate.
Rationale: A therapeutic aPTT is generally 1.5 to 2.5 times the control. An aPTT of 120
seconds is critically high and indicates a significant risk for spontaneous hemorrhage. The
infusion must be stopped, and the antidote (protamine sulfate) should be available.
Question 12
While assessing a client with recurring chest pain, the provider calls the nurse's station. What
should the nurse instruct the unit secretary to do?
A) Transfer the call into the client's room
B) Ask the provider the reason for the call
C) Ask another nurse to take the call so the primary nurse can stay with the client
D) Tell the provider to come to the unit immediately
E) Take a message and tell the provider the nurse is busy
Correct Answer: C) Ask another nurse to take the phone call.
Rationale: Patient safety during a potential cardiac event is the priority. The primary nurse
must stay at the bedside to complete the assessment and monitor the patient. Delegating the
COMPREHENSIVE B EVOLVE PRACTICE QUESTIONS AND ANSWERS LATEST 2025/2026
UPDATE
Question 1
The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral
tube feedings. Which task performed by the Unlicensed Assistive Personnel (UAP) requires
immediate intervention by the nurse?
A) Suctioning oral secretions from the mouth with a Yankauer
B) Positioning the head of the bed flat while changing the bottom sheets
C) Taking the client's temperature using the axillary method
D) Keeping the head of the bed elevated at 30 degrees during the feeding
E) Documenting the amount of water used for a flush
Correct Answer: B) Positions head of bed flat when changing sheets
Rationale: Positioning the head of the bed flat while enteral feedings are in progress or
immediately after significantly increases the risk of aspiration and subsequent pneumonia.
The nurse must ensure the HOB remains elevated at least 30 to 45 degrees. Suctioning oral
secretions and taking axillary temperatures are within the UAP’s scope of practice.
Question 2
A postsurgical client has received multiple units of packed red blood cells. Which laboratory
finding should the nurse prioritize for immediate reporting to the healthcare provider?
A) Serum Sodium level of 137 mEq/L
B) Serum Potassium level of 5.5 mEq/L
C) Blood Urea Nitrogen (BUN) level of 18 mg/dL
D) Serum Calcium level of 10 mg/dL
E) Hemoglobin level of 11 g/dL
Correct Answer: B) Potassium level, 5.5 mEq/L
Rationale: Stored blood undergoes hemolysis over time, which releases potassium into the
plasma. Multiple blood transfusions are a known risk factor for hyperkalemia. A potassium
level above 5.0 mEq/L is a critical finding that can lead to life-threatening cardiac
arrhythmias.
Question 3
Which vaccination is a priority for the nurse to administer to a newborn prior to hospital
discharge?
A) Hepatitis B
B) Human Papillomavirus (HPV)
C) Varicella
D) Meningococcal vaccine
E) Rotavirus
Correct Answer: A) Hepatitis B
Rationale: The Hepatitis B vaccine is the only immunization recommended at birth. HPV is
, 2
typically given during adolescence, Varicella at 12 months, and Meningococcal starting at
age 2 or later depending on risk factors.
Question 4
The nurse is managing a busy medical unit. Which task is most appropriate to delegate to the
Unlicensed Assistive Personnel (UAP)?
A) Assessing the integrity of a central line dressing
B) Obtaining a fingerstick blood glucose level
C) Explaining the plan of care to a concerned family member
D) Teaching a client about the side effects of new medications
E) Evaluating the effectiveness of an incentive spirometer
Correct Answer: B) Obtain a fingerstick blood glucose level.
Rationale: Obtaining a fingerstick glucose is a routine technical task that can be delegated
to a trained UAP. Assessment, teaching, evaluation, and discussing the medical plan of care
require the clinical judgment and specialized knowledge of a licensed nurse.
Question 5
A client with an ischemic stroke is receiving tissue plasminogen activator (t-PA) IV. Which
interventions should the nurse include in the plan of care? (Select all that apply.)
A) Administer 325 mg of Aspirin concurrently with the t-PA
B) Complete the National Institute of Health Stroke Scale (NIHSS)
C) Monitor closely for signs of internal or external bleeding
D) Administer the t-PA within 6 hours of symptom onset
E) Initiate a multidisciplinary consult for physical and occupational therapy
Correct Answer: B, C, E) Complete the National Institute of Health Stroke Scale (NIHSS);
Assess the client for signs of bleeding during and after the infusion; Initiate
multidisciplinary consult for potential rehabilitation.
Rationale: NIHSS provides a baseline and ongoing neurological assessment. Bleeding is the
primary complication of fibrinolytic therapy. Multidisciplinary rehab is essential for stroke
recovery. Aspirin is contraindicated during the first 24 hours of t-PA to prevent
hemorrhage. For stroke, t-PA must be given within 3 to 4.5 hours of symptom onset.
Question 6
When monitoring a client in active labor, which finding requires the most immediate notification
to the primary health care provider?
A) Maternal heart rate of 90 beats/min
B) Fetal heart rate of 100 beats/min
C) Maternal blood pressure of 140/86 mm Hg
D) Maternal temperature of 100.0° F
E) Contractions occurring every 3 minutes
Correct Answer: B) Fetal heart rate, 100 beats/min
, 3
Rationale: The normal fetal heart rate range is 110 to 160 beats/min. A rate of 100 beats/min
constitutes fetal bradycardia and may indicate fetal distress/hypoxia. The other vital signs
are within normal or expected limits for a client in labor.
Question 7
A client with heart failure develops acute respiratory distress and begins coughing up pink,
frothy sputum. Which nursing action is the priority?
A) Draw arterial blood gases (ABGs)
B) Notify the primary health care provider
C) Position the client in high Fowler’s with legs dangling
D) Obtain a portable chest X-ray
E) Auscultate the lungs for crackles
Correct Answer: C) Position in a high Fowler's position with the legs down.
Rationale: Pink frothy sputum is a hallmark of acute pulmonary edema. Positioning the
patient upright with the legs down (dangling) immediately decreases venous return
(preload) to the heart, which helps relieve pulmonary congestion. Other actions are
necessary but follow immediate positioning.
Question 8
A client prescribed Chlorpromazine HCl (Thorazine) for schizophrenia develops a shuffling gait,
tremors, and muscle rigidity. Which medication should the nurse expect to administer?
A) Benztropine mesylate (Cogentin)
B) Haloperidol (Haldol)
C) Lorazepam (Ativan)
D) Fluoxetine (Prozac)
E) Quetiapine (Seroquel)
Correct Answer: A) Administer a dose of benztropine mesylate (Cogentin) PRN.
Rationale: Shuffling gait, tremors, and rigidity are extrapyramidal side effects (EPS) or
pseudoparkinsonism caused by typical antipsychotics like Thorazine. Cogentin is an
anticholinergic used to reverse these side effects.
Question 9
During a well-child visit, which developmental finding in an infant should the nurse report for
further evaluation?
A) A two-month-old who cannot roll from back to stomach
B) A ten-month-old who cannot sit without support
C) A nine-month-old who cries when the parent leaves the room
D) An eight-month-old who has not yet spoken their first word
E) A six-month-old who reaches for a toy
Correct Answer: B) Ten-month-old who cannot sit without support
Rationale: Infants should be able to sit unsupported by 8 months of age. Rolling over occurs
, 4
by 5–6 months. Stranger anxiety (crying when the parent leaves) is normal between 7–9
months. The first words are not expected until approximately 12 months.
Question 10
Which dietary instruction is essential for a client hospitalized with an acute exacerbation of
ulcerative colitis?
A) Increase intake of raw fruits and vegetables
B) Follow a strict fluid restriction of 1 liter
C) Maintain a low-residue diet
D) Add whole milk to every meal
E) Eat high-fiber bran muffins for breakfast
Correct Answer: C) Provide a low-residue diet.
Rationale: A low-residue (low-fiber) diet reduces the amount of undigested food moving
through the colon, which helps decrease the frequency of diarrhea and provides "bowel
rest" during an acute flare of ulcerative colitis.
Question 11
The nurse is monitoring a client with deep vein thrombosis (DVT) on a continuous IV heparin
infusion. The current aPTT is 120 seconds. Which action is most appropriate?
A) Increase the infusion rate per the hospital's nomogram
B) Administer Vitamin K intramuscularly
C) Continue the infusion at the same rate and re-check in 4 hours
D) Stop the heparin drip and prepare to administer protamine sulfate
E) Switch the patient to oral Warfarin immediately
Correct Answer: D) Stop the heparin drip and prepare to administer protamine sulfate.
Rationale: A therapeutic aPTT is generally 1.5 to 2.5 times the control. An aPTT of 120
seconds is critically high and indicates a significant risk for spontaneous hemorrhage. The
infusion must be stopped, and the antidote (protamine sulfate) should be available.
Question 12
While assessing a client with recurring chest pain, the provider calls the nurse's station. What
should the nurse instruct the unit secretary to do?
A) Transfer the call into the client's room
B) Ask the provider the reason for the call
C) Ask another nurse to take the call so the primary nurse can stay with the client
D) Tell the provider to come to the unit immediately
E) Take a message and tell the provider the nurse is busy
Correct Answer: C) Ask another nurse to take the phone call.
Rationale: Patient safety during a potential cardiac event is the priority. The primary nurse
must stay at the bedside to complete the assessment and monitor the patient. Delegating the
