HESI EXIT COMPREHENSIVE EVOLVE PRACTICE B WITH NGN EXAM
QUESTIONS AND CORRECT ASNWERS WITH RATIONALES 2024-
2024 LATEST//GRADED A+
QUESTION: 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). - Correct Answer-
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
QUESTION: 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). - Correct Answer-
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
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,D. Calcium level, 10 mEq/L
QUESTION: 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). - Correct Answer-
Which vaccination should the nurse administer to a newborn?
A. Hepatitis B
B. Human papilloma virus (HPV)
C. Varicella
D. Meningococcal vaccine
QUESTION: 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. - Correct
Answer-
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.
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,QUESTION: 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). - Correct Answer-
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.
QUESTION: 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. - Correct Answer-
When caring for a client in labor, which finding is most important to report to the primary
health care provider?
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, 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
QUESTION: 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). - Correct Answer-
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.
QUESTION: A
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). - Correct Answer-
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QUESTIONS AND CORRECT ASNWERS WITH RATIONALES 2024-
2024 LATEST//GRADED A+
QUESTION: 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). - Correct Answer-
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
QUESTION: 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). - Correct Answer-
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
1|Page
,D. Calcium level, 10 mEq/L
QUESTION: 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). - Correct Answer-
Which vaccination should the nurse administer to a newborn?
A. Hepatitis B
B. Human papilloma virus (HPV)
C. Varicella
D. Meningococcal vaccine
QUESTION: 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. - Correct
Answer-
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.
2|Page
,QUESTION: 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). - Correct Answer-
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.
QUESTION: 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. - Correct Answer-
When caring for a client in labor, which finding is most important to report to the primary
health care provider?
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, 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
QUESTION: 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). - Correct Answer-
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.
QUESTION: A
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). - Correct Answer-
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