HESI EXIT Comprehensive B Evolve Practice Questions
with 100% Correct Answers | Latest Version (2024/2025)
Expert Verified
An 8-year-old child is receiving digoxin (Lanoxin) for congestive heart failure
(CHF). In assessing the child, the nurse finds that her apical heart rate is 80
beats/min, she complains of being slightly nauseated, and her serum digoxin
level is 1.2 ng/mL. What action should the nurse take?
A.Because the child's heart rate and digoxin level are within normal range,
assess for the cause of the nausea.
B.Hold the next dose of digoxin until the health care provider can be notified
because the serum digoxin level is elevated.
C.Administer the next dose of digoxin and notify the health care provider that
the child is showing signs of toxicity.
D.Notify the health care provider that the child's pulse rate is below normal for
her age group. - Correct Answer-A
Rationale:
TheTnurseTisTcaringTforTaTclientTwithTaTcerebrovascularTaccidentT(CVA)TwhoTisTre
ceivingTenteralTtubeTfeedings.TWhichTtaskTperformedTbyTtheTUAPTrequiresTimm
ediateTinterventionTbyTtheTnurse?
A.SuctionsToralTsecretionsTfromTmouth
B.PositionsTheadTofTbedTflatTwhenTchangingTsheets
C.TakesTtemperatureTusingTtheTaxillaryTmethod
D.KeepsTheadTofTbedTelevatedTatT30TdegreesT-TCorrectTAnswer-B
Rationale:
,PositioningTtheTheadTofTtheTbedTflatTwhenTenteralTfeedingsTareTinTprogressTputs
TtheTclientTatTriskTforTaspirationT(B).TTheTothersTareTallTacceptableTtasksTperform
edTbyTtheTUAPT(A,TC,TandTD).
WhenTcaringTforTaTpostsurgicalTclientTwhoThasTundergoneTmultipleTbloodTtransf
usions,TwhichTserumTlaboratoryTfindingTisTofTmostTconcernTtoTtheTnurse?
A.SodiumTlevel,T137TmEq/L
B.PotassiumTlevel,T5.5TmEq/L
C.BloodTureaTnitrogenT(BUN)Tlevel,T18Tmg/dL
D.CalciumTlevel,T10TmEq/LT-TCorrectTAnswer-B
Rationale:
MultipleTbloodTtransfusionsTareTaTriskTfactorTforThyperkalemia.TATserumTpotassi
umTlevelThigherTthanT5.0TmEq/LTindicatesThyperkalemiaT(B).TTheTothersTareTnor
malTfindingsT(A,TC,TandTD).
WhichTvaccinationTshouldTtheTnurseTadministerTtoTaTnewborn?
A.HepatitisTB
B.HumanTpapillomaTvirusT(HPV)
C.Varicella
D.MeningococcalTvaccineT-TCorrectTAnswer-A
Rationale:
TheThepatitisTBTvaccinationTshouldTbeTgivenTtoTallTnewbornsTbeforeThospitalTdis
chargeT(A).THPVTisTnotTrecommendedTuntilTadolescenceT(B).TVaricellaTimmuniza
tionTbeginsTatT12TmonthsT(C).TMeningococcalTvaccineTisTadministeredTbeginning
TatT2TyearsT(D).
,TheTnurseTisTcaringTforTaTclientTonTtheTmedicalTunit.TWhichTtaskTcanTbeTdelegate
dTtoTunlicensedTassistiveTpersonnelT(UAP)?
A.AssessTtheTneedTtoTchangeTaTcentralTlineTdressing.
B.ObtainTaTfingerstickTbloodTglucoseTlevel.
C.AnswerTaTfamilyTmember'sTquestionsTaboutTtheTclient'sTplanTofTcare.
D.TeachTtheTclientTsideTeffectsTtoTreportTrelatedTtoTtheTcurrentTmedicationTregi
men.T-TCorrectTAnswer-B
Rationale:
ObtainingTaTfingerstickTbloodTglucoseTlevelTisTaTsimpleTtreatmentTandTisTanTappr
opriateTskillTforTUAPTtoTperformT(B).T(A,TC,TandTD)TareTskillsTthatTcannotTbeTdele
gatedTtoTUAP.
TheTnurseTisTcaringTforTaTclientTwithTanTischemicTstrokeTwhoThasTaTprescriptionT
forTtissueTplasminogenTactivatorT(t-
PA)TIV.TWhichTaction(s)TshouldTtheTnurseTexpectTtoTimplement?T(SelectTallTthatT
apply.)
A.AdministerTaspirinTwithTtissueTplasminogenTactivatorT(t-PA).
B.CompleteTtheTNationalTInstituteTofTHealthTStrokeTScaleT(NIHSS).
C.AssessTtheTclientTforTsignsTofTbleedingTduringTandTafterTtheTinfusion.
D.StartTt-PATwithinT6ThoursTafterTtheTonsetTofTstrokeTsymptoms.
E.InitiateTmultidisciplinaryTconsultTforTpotentialTrehabilitation.T-
TCorrectTAnswer-B,C,E
Rationale:
NeurologicTassessment,TincludingTtheTNIHSS,TisTindicatedTforTtheTclientTreceivin
gTt-
PA.TThisTincludesTcloseTmonitoringTforTbleedingTduringTandTafterTtheTinfusion;Tif
TbleedingTorTotherTsignsTofTneurologicTimpairmentToccur,TtheTinfusionTshouldTb
eTstoppedT(B,TC,TandTE).TAspirinTisTcontraindicatedTwithTt-
, PATbecauseTitTincreasesTtheTriskTforTbleedingT(A).TTheTadministrationTofTt-
PATwithinT6ThoursTofTsymptomsTisTconcurrentTwithTaTdiagnosisTofTaTmyocardialT
infarctionTandTwithinT4.5ThoursTofTsymptomsTisTconcurrentTforTaTstrokeT(D).
WhenTcaringTforTaTclientTinTlabor,TwhichTfindingTisTmostTimportantTtoTreportTtoT
theTprimaryThealthTcareTprovider?
A.MaternalTheartTrate,T90Tbeats/min.
B.FetalTheartTrate,T100Tbeats/min
C.MaternalTbloodTpressure,T140/86TmmTHg
D.MaternalTtemperature,T100.0°TFT-TCorrectTAnswer-B
Rationale:
ATfetalTheartTrateT(FHR)TofT100Tbeats/minTmayTindicateTfetalTdistressT(B)Tbecaus
eTtheTaverageTFHRTatTtermTisT140Tbeats/minTandTtheTnormalTrangeTisT110TtoTbe
ats/minT160.TTheTothersT(A,TC,TandTD)TareTnormalTfindingsTforTaTwomanTinTlabor
.
TheTnurseTisTcaringTforTaTclientTwithTheartTfailureTwhoTdevelopsTrespiratoryTdist
ressTandTcoughsTupTpinkTfrothyTsputum.TWhichTactionTshouldTtheTnurseTtakeTfir
st?
A.DrawTarterialTbloodTgases.
B.NotifyTtheTprimaryThealthTcareTprovider.
C.PositionTinTaThighTFowler'sTpositionTwithTtheTlegsTdown.
D.ObtainTaTchestTX-ray.T-TCorrectTAnswer-C
Rationale:
PositioningTtheTpatientTinTaThighTFowler'sTpositionTwithTdanglingTfeetTwillTdecre
aseTfurtherTvenousTreturnTtoTtheTleftTventricleT(C).TTheTotherTactionsTshouldTbeT
performedTafterTtheTchangeTinTpositionT(A,TB,TandTD).
with 100% Correct Answers | Latest Version (2024/2025)
Expert Verified
An 8-year-old child is receiving digoxin (Lanoxin) for congestive heart failure
(CHF). In assessing the child, the nurse finds that her apical heart rate is 80
beats/min, she complains of being slightly nauseated, and her serum digoxin
level is 1.2 ng/mL. What action should the nurse take?
A.Because the child's heart rate and digoxin level are within normal range,
assess for the cause of the nausea.
B.Hold the next dose of digoxin until the health care provider can be notified
because the serum digoxin level is elevated.
C.Administer the next dose of digoxin and notify the health care provider that
the child is showing signs of toxicity.
D.Notify the health care provider that the child's pulse rate is below normal for
her age group. - Correct Answer-A
Rationale:
TheTnurseTisTcaringTforTaTclientTwithTaTcerebrovascularTaccidentT(CVA)TwhoTisTre
ceivingTenteralTtubeTfeedings.TWhichTtaskTperformedTbyTtheTUAPTrequiresTimm
ediateTinterventionTbyTtheTnurse?
A.SuctionsToralTsecretionsTfromTmouth
B.PositionsTheadTofTbedTflatTwhenTchangingTsheets
C.TakesTtemperatureTusingTtheTaxillaryTmethod
D.KeepsTheadTofTbedTelevatedTatT30TdegreesT-TCorrectTAnswer-B
Rationale:
,PositioningTtheTheadTofTtheTbedTflatTwhenTenteralTfeedingsTareTinTprogressTputs
TtheTclientTatTriskTforTaspirationT(B).TTheTothersTareTallTacceptableTtasksTperform
edTbyTtheTUAPT(A,TC,TandTD).
WhenTcaringTforTaTpostsurgicalTclientTwhoThasTundergoneTmultipleTbloodTtransf
usions,TwhichTserumTlaboratoryTfindingTisTofTmostTconcernTtoTtheTnurse?
A.SodiumTlevel,T137TmEq/L
B.PotassiumTlevel,T5.5TmEq/L
C.BloodTureaTnitrogenT(BUN)Tlevel,T18Tmg/dL
D.CalciumTlevel,T10TmEq/LT-TCorrectTAnswer-B
Rationale:
MultipleTbloodTtransfusionsTareTaTriskTfactorTforThyperkalemia.TATserumTpotassi
umTlevelThigherTthanT5.0TmEq/LTindicatesThyperkalemiaT(B).TTheTothersTareTnor
malTfindingsT(A,TC,TandTD).
WhichTvaccinationTshouldTtheTnurseTadministerTtoTaTnewborn?
A.HepatitisTB
B.HumanTpapillomaTvirusT(HPV)
C.Varicella
D.MeningococcalTvaccineT-TCorrectTAnswer-A
Rationale:
TheThepatitisTBTvaccinationTshouldTbeTgivenTtoTallTnewbornsTbeforeThospitalTdis
chargeT(A).THPVTisTnotTrecommendedTuntilTadolescenceT(B).TVaricellaTimmuniza
tionTbeginsTatT12TmonthsT(C).TMeningococcalTvaccineTisTadministeredTbeginning
TatT2TyearsT(D).
,TheTnurseTisTcaringTforTaTclientTonTtheTmedicalTunit.TWhichTtaskTcanTbeTdelegate
dTtoTunlicensedTassistiveTpersonnelT(UAP)?
A.AssessTtheTneedTtoTchangeTaTcentralTlineTdressing.
B.ObtainTaTfingerstickTbloodTglucoseTlevel.
C.AnswerTaTfamilyTmember'sTquestionsTaboutTtheTclient'sTplanTofTcare.
D.TeachTtheTclientTsideTeffectsTtoTreportTrelatedTtoTtheTcurrentTmedicationTregi
men.T-TCorrectTAnswer-B
Rationale:
ObtainingTaTfingerstickTbloodTglucoseTlevelTisTaTsimpleTtreatmentTandTisTanTappr
opriateTskillTforTUAPTtoTperformT(B).T(A,TC,TandTD)TareTskillsTthatTcannotTbeTdele
gatedTtoTUAP.
TheTnurseTisTcaringTforTaTclientTwithTanTischemicTstrokeTwhoThasTaTprescriptionT
forTtissueTplasminogenTactivatorT(t-
PA)TIV.TWhichTaction(s)TshouldTtheTnurseTexpectTtoTimplement?T(SelectTallTthatT
apply.)
A.AdministerTaspirinTwithTtissueTplasminogenTactivatorT(t-PA).
B.CompleteTtheTNationalTInstituteTofTHealthTStrokeTScaleT(NIHSS).
C.AssessTtheTclientTforTsignsTofTbleedingTduringTandTafterTtheTinfusion.
D.StartTt-PATwithinT6ThoursTafterTtheTonsetTofTstrokeTsymptoms.
E.InitiateTmultidisciplinaryTconsultTforTpotentialTrehabilitation.T-
TCorrectTAnswer-B,C,E
Rationale:
NeurologicTassessment,TincludingTtheTNIHSS,TisTindicatedTforTtheTclientTreceivin
gTt-
PA.TThisTincludesTcloseTmonitoringTforTbleedingTduringTandTafterTtheTinfusion;Tif
TbleedingTorTotherTsignsTofTneurologicTimpairmentToccur,TtheTinfusionTshouldTb
eTstoppedT(B,TC,TandTE).TAspirinTisTcontraindicatedTwithTt-
, PATbecauseTitTincreasesTtheTriskTforTbleedingT(A).TTheTadministrationTofTt-
PATwithinT6ThoursTofTsymptomsTisTconcurrentTwithTaTdiagnosisTofTaTmyocardialT
infarctionTandTwithinT4.5ThoursTofTsymptomsTisTconcurrentTforTaTstrokeT(D).
WhenTcaringTforTaTclientTinTlabor,TwhichTfindingTisTmostTimportantTtoTreportTtoT
theTprimaryThealthTcareTprovider?
A.MaternalTheartTrate,T90Tbeats/min.
B.FetalTheartTrate,T100Tbeats/min
C.MaternalTbloodTpressure,T140/86TmmTHg
D.MaternalTtemperature,T100.0°TFT-TCorrectTAnswer-B
Rationale:
ATfetalTheartTrateT(FHR)TofT100Tbeats/minTmayTindicateTfetalTdistressT(B)Tbecaus
eTtheTaverageTFHRTatTtermTisT140Tbeats/minTandTtheTnormalTrangeTisT110TtoTbe
ats/minT160.TTheTothersT(A,TC,TandTD)TareTnormalTfindingsTforTaTwomanTinTlabor
.
TheTnurseTisTcaringTforTaTclientTwithTheartTfailureTwhoTdevelopsTrespiratoryTdist
ressTandTcoughsTupTpinkTfrothyTsputum.TWhichTactionTshouldTtheTnurseTtakeTfir
st?
A.DrawTarterialTbloodTgases.
B.NotifyTtheTprimaryThealthTcareTprovider.
C.PositionTinTaThighTFowler'sTpositionTwithTtheTlegsTdown.
D.ObtainTaTchestTX-ray.T-TCorrectTAnswer-C
Rationale:
PositioningTtheTpatientTinTaThighTFowler'sTpositionTwithTdanglingTfeetTwillTdecre
aseTfurtherTvenousTreturnTtoTtheTleftTventricleT(C).TTheTotherTactionsTshouldTbeT
performedTafterTtheTchangeTinTpositionT(A,TB,TandTD).
