EXIT HESI Comprehensive B Evolve Practice Questions with
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). - -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
-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). - -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
-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). - -Which vaccination should the nurse administer to a
newborn?
A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
D.Meningococcal vaccine
-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 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.
-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). - -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.
-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. - -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
-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).
- -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.
-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). - -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?A.Administer a dose of benztropine mesylate (Cogentin) PRN.
B.Determine if the client has increased photosensitivity.
C.Provide comfort measures for sore muscles.
D.Assess the client for visual and auditory hallucinations.
-B
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). - -A nurse is interviewing a mother during
a well-child visit. Which finding would alert the nurse to continue 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
-C
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. - -Which
intervention should be included in the plan of care for a client admitted to the hospital with ulcerative
colitis?
A.Administer stool softeners.
B.Place the client on fluid restriction.
C.Provide a low-residue diet.
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). - -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
-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). - -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
-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). - -Which vaccination should the nurse administer to a
newborn?
A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
D.Meningococcal vaccine
-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 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.
-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). - -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.
-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. - -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
-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).
- -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.
-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). - -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?A.Administer a dose of benztropine mesylate (Cogentin) PRN.
B.Determine if the client has increased photosensitivity.
C.Provide comfort measures for sore muscles.
D.Assess the client for visual and auditory hallucinations.
-B
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). - -A nurse is interviewing a mother during
a well-child visit. Which finding would alert the nurse to continue 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
-C
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. - -Which
intervention should be included in the plan of care for a client admitted to the hospital with ulcerative
colitis?
A.Administer stool softeners.
B.Place the client on fluid restriction.
C.Provide a low-residue diet.
