HESI Exit Comprehensive B Evolve Practice
Exam |Complete Exam Questions with 100%
Verified Correct Answers and Rationales |
Latest Update 2026/2027
Question 1
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
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).
Question 2
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
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).
Question 3
Which vaccination should the nurse administer to a newborn?
pg. 1
,A. Hepatitis B
B. Human papilloma virus (HPV)
C. Varicella
D. Meningococcal vaccine
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).
Question 4
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
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.
Question 5
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
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
pg. 2
,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).
Question 6
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
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 160
beats/min. The others (A, C, and D) are normal findings for a woman in labor.
Question 7
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
Answer: C
Rationale: The client is experiencing pulmonary edema. Positioning in high Fowler's
with legs down promotes venous return and reduces preload, which is the priority
intervention (C). (A, B, and D) should be implemented after positioning.
Question 8
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
pg. 3
, Answer: A
Rationale: Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia,
and mask-like 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).
Question 9
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
Answer: 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).
Question 10
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
D. Add a milk product to each meal
Answer: 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.
Question 11
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
pg. 4
Exam |Complete Exam Questions with 100%
Verified Correct Answers and Rationales |
Latest Update 2026/2027
Question 1
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
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).
Question 2
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
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).
Question 3
Which vaccination should the nurse administer to a newborn?
pg. 1
,A. Hepatitis B
B. Human papilloma virus (HPV)
C. Varicella
D. Meningococcal vaccine
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).
Question 4
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
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.
Question 5
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
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
pg. 2
,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).
Question 6
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
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 160
beats/min. The others (A, C, and D) are normal findings for a woman in labor.
Question 7
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
Answer: C
Rationale: The client is experiencing pulmonary edema. Positioning in high Fowler's
with legs down promotes venous return and reduces preload, which is the priority
intervention (C). (A, B, and D) should be implemented after positioning.
Question 8
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
pg. 3
, Answer: A
Rationale: Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia,
and mask-like 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).
Question 9
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
Answer: 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).
Question 10
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
D. Add a milk product to each meal
Answer: 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.
Question 11
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
pg. 4
