EXIT HESI COMPREHENSIVE B EVOLVE
PRACTICE QUESTIONS/EXIT HESI
COMPREHENSIVE B EVOLVE PRACTICE
QUESTIONS AND ANSWERS LATEST
2025/2026 UPDATE
Q1. 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. The others are all
acceptable tasks performed by the UAP .
Q2. 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. The others are normal findings .
Q3. 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. HPV is not recommended until adolescence.
Varicella immunization begins at 12 months. Meningococcal vaccine is
administered beginning at 2 years .
Q4. 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. The other
options are skills that cannot be delegated to UAP .
Q5. 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,,,s: 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. Aspirin is
, contraindicated with t-PA because it increases the risk for bleeding. 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 .
Q6. 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 because the average FHR at term is 140 beats/min and the
normal range is 110 to 160 beats/min. The others are normal findings for
a woman in labor .
Q7. 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
PRACTICE QUESTIONS/EXIT HESI
COMPREHENSIVE B EVOLVE PRACTICE
QUESTIONS AND ANSWERS LATEST
2025/2026 UPDATE
Q1. 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. The others are all
acceptable tasks performed by the UAP .
Q2. 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. The others are normal findings .
Q3. 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. HPV is not recommended until adolescence.
Varicella immunization begins at 12 months. Meningococcal vaccine is
administered beginning at 2 years .
Q4. 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. The other
options are skills that cannot be delegated to UAP .
Q5. 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,,,s: 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. Aspirin is
, contraindicated with t-PA because it increases the risk for bleeding. 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 .
Q6. 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 because the average FHR at term is 140 beats/min and the
normal range is 110 to 160 beats/min. The others are normal findings for
a woman in labor .
Q7. 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
