COMPREHENSIVE EXIT HESI
EVOLVE EXAM QUESTIONS AND ANSWERS
2025\2026
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 .(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?
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 .(B). .The .others .are .normal .findings .(A, .C, .and .D).
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 .(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)?
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 .(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.)
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 .-
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 .(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?
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 .(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?
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. .- .CORRECT .ANSWER .-
C .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).
EVOLVE EXAM QUESTIONS AND ANSWERS
2025\2026
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 .(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?
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 .(B). .The .others .are .normal .findings .(A, .C, .and .D).
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 .(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)?
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 .(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.)
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 .-
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 .(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?
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 .(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?
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. .- .CORRECT .ANSWER .-
C .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).
