EXIT HESI Comprehensive B Evolve Practice
Questions and Answers 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 intervention by the nurse? - ANSWER>>B.Positions head of bed flat
when changing sheets
Rationale:
Positioning the head of the bed flat when enteral feedings are in progress puts
the client at risk for aspiration (B). The others are all acceptable tasks performed
by the UAP (A, C, and D).
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:
A low-residue diet (C) will help decrease symptoms of diarrhea, which are clinical
manifestations of ulcerative colitis. (A, B, and D) are contraindicated and could
worsen the condition.
The nurse is caring for a client with deep vein thrombosis who is on a continuous
IV heparin infusion. The activated partial prothrombin time (aPTT) is 120 seconds.
Which action should the nurse take? - ANSWER>>D. Stop the heparin drip and
prepare to administer protamine sulfate.
Rationale:
An aPTT more than 100 seconds is a critically high value; therefore, the heparin
should be stopped. The antidote for heparin is protamine sulfate (D). Increasing
the rate would increase the risk for hemorrhage (A). The infusion should be
stopped, and vitamin K is the antidote for warfarin (Coumadin) (B). Keeping the
infusion at the current rate would increase the risk for hemorrhage (C).
While assessing a client with recurring chest pain, the unit secretary notifies the
nurse that the client's health care provider is on the telephone. What action
should the nurse instruct the unit secretary to implement? - ANSWER>>C. Ask
another nurse to take the phone call.
Rationale:
Another nurse should be asked to take the phone call (C), which allows the nurse
to stay at the bedside to complete the assessment of the client's chest pain. (A
and B) should not be done during an acute change in the client's condition.
Requesting the health care provider (D) to come to the unit is premature until the
nurse completes assessment of the client's status.
Which instruction(s) should the nurse include in the discharge teaching plan of a
male client who has had a myocardial infarction and who has a new prescription
Questions and Answers 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 intervention by the nurse? - ANSWER>>B.Positions head of bed flat
when changing sheets
Rationale:
Positioning the head of the bed flat when enteral feedings are in progress puts
the client at risk for aspiration (B). The others are all acceptable tasks performed
by the UAP (A, C, and D).
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:
A low-residue diet (C) will help decrease symptoms of diarrhea, which are clinical
manifestations of ulcerative colitis. (A, B, and D) are contraindicated and could
worsen the condition.
The nurse is caring for a client with deep vein thrombosis who is on a continuous
IV heparin infusion. The activated partial prothrombin time (aPTT) is 120 seconds.
Which action should the nurse take? - ANSWER>>D. Stop the heparin drip and
prepare to administer protamine sulfate.
Rationale:
An aPTT more than 100 seconds is a critically high value; therefore, the heparin
should be stopped. The antidote for heparin is protamine sulfate (D). Increasing
the rate would increase the risk for hemorrhage (A). The infusion should be
stopped, and vitamin K is the antidote for warfarin (Coumadin) (B). Keeping the
infusion at the current rate would increase the risk for hemorrhage (C).
While assessing a client with recurring chest pain, the unit secretary notifies the
nurse that the client's health care provider is on the telephone. What action
should the nurse instruct the unit secretary to implement? - ANSWER>>C. Ask
another nurse to take the phone call.
Rationale:
Another nurse should be asked to take the phone call (C), which allows the nurse
to stay at the bedside to complete the assessment of the client's chest pain. (A
and B) should not be done during an acute change in the client's condition.
Requesting the health care provider (D) to come to the unit is premature until the
nurse completes assessment of the client's status.
Which instruction(s) should the nurse include in the discharge teaching plan of a
male client who has had a myocardial infarction and who has a new prescription
