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HESI COMPREHENSIVE B,
COMPREHENSIVE EXAM A, EXIT V 2-322
QUESTIONS FULLY SOLVED &
UPDATED 2024
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 interven琀椀on by the nurse?
A.Suc琀椀ons oral secre琀椀ons from mouth
B.Posi琀椀ons head of bed 昀氀at when changing sheets
C.Takes temperature using the axillary method
D.Keeps head of bed elevated at 30 degrees - answer B
Ra琀椀onale:
Posi琀椀oning the head of the bed 昀氀at when enteral feedings are in progress puts the client at risk
for aspira琀椀on (B). The others are all acceptable tasks performed by the UAP (A, C, and D).
When caring for a postsurgical client who has undergone mul琀椀ple blood transfusions, which
serum laboratory 昀椀nding 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
Ra琀椀onale:
Mul琀椀ple 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 昀椀ndings (A, C, and D).
Which vaccina琀椀on should the nurse administer to a newborn?
A.Hepa琀椀琀椀s B
B.Human papilloma virus (HPV)
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C.Varicella
D.Meningococcal vaccine - answer A
Ra琀椀onale:
The hepa琀椀琀椀s B vaccina琀椀on should be given to all newborns before hospital discharge (A). HPV is
not recommended un琀椀l adolescence (B). Varicella immuniza琀椀on 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
assis琀椀ve personnel (UAP)?
A.Assess the need to change a central line dressing.
B.Obtain a 昀椀ngers琀椀ck blood glucose level.
C.Answer a family member's ques琀椀ons about the client's plan of care.
D.Teach the client side e昀昀ects to report related to the current medica琀椀on regimen. - answer B
Ra琀椀onale:
Obtaining a 昀椀ngers琀椀ck 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 prescrip琀椀on for 琀椀ssue
plasminogen ac琀椀vator (t-PA) IV. Which ac琀椀on(s) should the nurse expect to implement? (Select
all that apply.)
A.Administer aspirin with 琀椀ssue plasminogen ac琀椀vator (t-PA).
B.Complete the Na琀椀onal Ins琀椀tute of Health Stroke Scale (NIHSS).
C.Assess the client for signs of bleeding during and a昀琀er the infusion.
D.Start t-PA within 6 hours a昀琀er the onset of stroke symptoms.
E.Ini琀椀ate mul琀椀disciplinary consult for poten琀椀al rehabilita琀椀on. - answer B,C,E
Ra琀椀onale:
Neurologic assessment, including the NIHSS, is indicated for the client receiving t-PA. This
includes close monitoring for bleeding during and a昀琀er 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 administra琀椀on of t-
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PA within 6 hours of symptoms is concurrent with a diagnosis of a myocardial infarc琀椀on and
within 4.5 hours of symptoms is concurrent for a stroke (D).
When caring for a client in labor, which 昀椀nding 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
Ra琀椀onale:
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 昀椀ndings 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 ac琀椀on should the nurse take 昀椀rst?
A.Draw arterial blood gases.
B.No琀椀fy the primary health care provider.
C.Posi琀椀on in a high Fowler's posi琀椀on with the legs down.
D.Obtain a chest X-ray. - answer C
Ra琀椀onale:
Posi琀椀oning the pa琀椀ent in a high Fowler's posi琀椀on with dangling feet will decrease further
venous return to the le昀琀 ventricle (C). The other ac琀椀ons should be performed a昀琀er the change
in posi琀椀on (A, B, and D).
A client who is prescribed chlorpromazine HCl (Thorazine) for schizophrenia develops rigidity, a
shu昀툀ing gait, and tremors. Which ac琀椀on by the nurse is most important?A.Administer a dose of
benztropine mesylate (Cogen琀椀n) PRN.
B.Determine if the client has increased photosensi琀椀vity.
C.Provide comfort measures for sore muscles.
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D.Assess the client for visual and auditory hallucina琀椀ons. - answer A
Ra琀椀onale:
Rigidity, shu昀툀ing gait, pill-rolling hand movements, tremors, dyskinesia, and masklike face are
extrapyramidal side e昀昀ects associated with Thorazine. It is most important for the nurse to
administer an an琀椀cholinergic such as Cogen琀椀n to reverse these e昀昀ects (A). The others (B, C, D)
may be appropriate interven琀椀ons but are not as urgent as (A).
A nurse is interviewing a mother during a well-child visit. Which 昀椀nding would alert the nurse to
con琀椀nue 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 - answer B
Ra琀椀onale:
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 interven琀椀on should be included in the plan of care for a client admi琀琀ed to the hospital
with ulcera琀椀ve coli琀椀s?
A.Administer stool so昀琀eners.
B.Place the client on 昀氀uid restric琀椀on.
C.Provide a low-residue diet.
D.Add a milk product to each meal. - answer C
Ra琀椀onale:
A low-residue diet (C) will help decrease symptoms of diarrhea, which are clinical manifesta琀椀ons
of ulcera琀椀ve coli琀椀s. (A, B, and D) are contraindicated and could worsen the condi琀椀on.
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HESI COMPREHENSIVE B,
COMPREHENSIVE EXAM A, EXIT V 2-322
QUESTIONS FULLY SOLVED &
UPDATED 2024
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 interven琀椀on by the nurse?
A.Suc琀椀ons oral secre琀椀ons from mouth
B.Posi琀椀ons head of bed 昀氀at when changing sheets
C.Takes temperature using the axillary method
D.Keeps head of bed elevated at 30 degrees - answer B
Ra琀椀onale:
Posi琀椀oning the head of the bed 昀氀at when enteral feedings are in progress puts the client at risk
for aspira琀椀on (B). The others are all acceptable tasks performed by the UAP (A, C, and D).
When caring for a postsurgical client who has undergone mul琀椀ple blood transfusions, which
serum laboratory 昀椀nding 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
Ra琀椀onale:
Mul琀椀ple 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 昀椀ndings (A, C, and D).
Which vaccina琀椀on should the nurse administer to a newborn?
A.Hepa琀椀琀椀s B
B.Human papilloma virus (HPV)
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C.Varicella
D.Meningococcal vaccine - answer A
Ra琀椀onale:
The hepa琀椀琀椀s B vaccina琀椀on should be given to all newborns before hospital discharge (A). HPV is
not recommended un琀椀l adolescence (B). Varicella immuniza琀椀on 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
assis琀椀ve personnel (UAP)?
A.Assess the need to change a central line dressing.
B.Obtain a 昀椀ngers琀椀ck blood glucose level.
C.Answer a family member's ques琀椀ons about the client's plan of care.
D.Teach the client side e昀昀ects to report related to the current medica琀椀on regimen. - answer B
Ra琀椀onale:
Obtaining a 昀椀ngers琀椀ck 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 prescrip琀椀on for 琀椀ssue
plasminogen ac琀椀vator (t-PA) IV. Which ac琀椀on(s) should the nurse expect to implement? (Select
all that apply.)
A.Administer aspirin with 琀椀ssue plasminogen ac琀椀vator (t-PA).
B.Complete the Na琀椀onal Ins琀椀tute of Health Stroke Scale (NIHSS).
C.Assess the client for signs of bleeding during and a昀琀er the infusion.
D.Start t-PA within 6 hours a昀琀er the onset of stroke symptoms.
E.Ini琀椀ate mul琀椀disciplinary consult for poten琀椀al rehabilita琀椀on. - answer B,C,E
Ra琀椀onale:
Neurologic assessment, including the NIHSS, is indicated for the client receiving t-PA. This
includes close monitoring for bleeding during and a昀琀er 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 administra琀椀on of t-
Downloaded by Brian Kariuki ()
, lOMoARcPSD|34465178
PA within 6 hours of symptoms is concurrent with a diagnosis of a myocardial infarc琀椀on and
within 4.5 hours of symptoms is concurrent for a stroke (D).
When caring for a client in labor, which 昀椀nding 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
Ra琀椀onale:
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 昀椀ndings 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 ac琀椀on should the nurse take 昀椀rst?
A.Draw arterial blood gases.
B.No琀椀fy the primary health care provider.
C.Posi琀椀on in a high Fowler's posi琀椀on with the legs down.
D.Obtain a chest X-ray. - answer C
Ra琀椀onale:
Posi琀椀oning the pa琀椀ent in a high Fowler's posi琀椀on with dangling feet will decrease further
venous return to the le昀琀 ventricle (C). The other ac琀椀ons should be performed a昀琀er the change
in posi琀椀on (A, B, and D).
A client who is prescribed chlorpromazine HCl (Thorazine) for schizophrenia develops rigidity, a
shu昀툀ing gait, and tremors. Which ac琀椀on by the nurse is most important?A.Administer a dose of
benztropine mesylate (Cogen琀椀n) PRN.
B.Determine if the client has increased photosensi琀椀vity.
C.Provide comfort measures for sore muscles.
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D.Assess the client for visual and auditory hallucina琀椀ons. - answer A
Ra琀椀onale:
Rigidity, shu昀툀ing gait, pill-rolling hand movements, tremors, dyskinesia, and masklike face are
extrapyramidal side e昀昀ects associated with Thorazine. It is most important for the nurse to
administer an an琀椀cholinergic such as Cogen琀椀n to reverse these e昀昀ects (A). The others (B, C, D)
may be appropriate interven琀椀ons but are not as urgent as (A).
A nurse is interviewing a mother during a well-child visit. Which 昀椀nding would alert the nurse to
con琀椀nue 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 - answer B
Ra琀椀onale:
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 interven琀椀on should be included in the plan of care for a client admi琀琀ed to the hospital
with ulcera琀椀ve coli琀椀s?
A.Administer stool so昀琀eners.
B.Place the client on 昀氀uid restric琀椀on.
C.Provide a low-residue diet.
D.Add a milk product to each meal. - answer C
Ra琀椀onale:
A low-residue diet (C) will help decrease symptoms of diarrhea, which are clinical manifesta琀椀ons
of ulcera琀椀ve coli琀椀s. (A, B, and D) are contraindicated and could worsen the condi琀椀on.
Downloaded by Brian Kariuki ()
