ADVANCED EXIT HESI
COMPREHENSIVE EXAM TEST
QUESTIONS AND ANSWERS
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 mB m
B.Human mpapilloma mvirus m(HPV) m
C.Varicella m
D.Meningococcal mvaccine m- mCORRECT mANSWER m-A m
Rationale: m
The mhepatitis mB mvaccination mshould mbe mgiven mto mall mnewborns mbefore mhospital mdischarge m(A). mHPV mis
mnot mrecommended muntil madolescence m(B). mVaricella mimmunization mbegins mat m12 mmonths m(C).
mMeningococcal mvaccine mis madministered mbeginning mat m2 myears m(D). m
m
The mnurse mis mcaring mfor ma mclient mon mthe mmedical munit. mWhich mtask mcan mbe mdelegated mto munlicensed
massistive mpersonnel m(UAP)? m
A.Assess mthe mneed mto mchange ma mcentral mline mdressing. m
B.Obtain ma mfingerstick mblood mglucose mlevel. m
C.Answer ma mfamily mmember's mquestions mabout mthe mclient's mplan mof mcare. m
D.Teach mthe mclient mside meffects mto mreport mrelated mto mthe mcurrent mmedication mregimen. m- mCORRECT
mANSWER m-B m
Rationale: m
Obtaining ma mfingerstick mblood mglucose mlevel mis ma msimple mtreatment mand mis man mappropriate mskill mfor
mUAP mto mperform m(B). m(A, mC, mand mD) mare mskills mthat mcannot mbe mdelegated mto mUAP. m
m
The mnurse mis mcaring mfor ma mclient mwith man mischemic mstroke mwho mhas ma mprescription mfor mtissue
m plasminogen mactivator m(t-PA) mIV. mWhich maction(s) mshould mthe mnurse mexpect mto mimplement? m(Select
m all mthat mapply.) mA.Administer maspirin mwith mtissue mplasminogen mactivator m(t-PA). m
B.Complete mthe mNational mInstitute mof mHealth mStroke mScale m(NIHSS). m
C.Assess mthe mclient mfor msigns mof mbleeding mduring mand mafter mthe minfusion. m
D.Start mt-PA mwithin m6 mhours mafter mthe monset mof mstroke msymptoms. m
E.Initiate mmultidisciplinary mconsult mfor mpotential mrehabilitation. m- mCORRECT mANSWER m-B,C,E m
Rationale: m
,Neurologic massessment, mincluding mthe mNIHSS, mis mindicated mfor mthe mclient mreceiving mt-PA. mThis
mincludes mclose mmonitoring mfor mbleeding mduring mand mafter mthe minfusion; mif mbleeding mor mother msigns
mof mneurologic mimpairment moccur, mthe minfusion mshould mbe mstopped m(B, mC, mand mE). mAspirin mis
mcontraindicated mwith mt-PA mbecause mit mincreases mthe mrisk mfor mbleeding m(A). mThe madministration mof mt-
PA mwithin m6 mhours mof msymptoms mis mconcurrent mwith ma mdiagnosis mof ma mmyocardial minfarction mand
mwithin m4.5 mhours mof msymptoms mis mconcurrent mfor ma mstroke m(D). m
m
When mcaring mfor ma mclient min mlabor, mwhich mfinding mis mmost mimportant mto mreport mto mthe mprimary
mhealth mcare mprovider? m
A.Maternal mheart mrate, m90 mbeats/min. m
B.Fetal mheart mrate, m100 mbeats/min m
C.Maternal mblood mpressure, m140/86 mmm mHg m
D.Maternal mtemperature, m100.0° mF m- mCORRECT mANSWER m-B m
Rationale: m
A mfetal mheart mrate m(FHR) mof m100 mbeats/min mmay mindicate mfetal mdistress m(B) mbecause mthe maverage
mFHR mat mterm mis m140 mbeats/min mand mthe mnormal mrange mis m110 mto mbeats/min m160. mThe mothers m(A, mC,
mand mD) mare mnormal mfindings mfor ma mwoman min mlabor. m
m
The mnurse mis mcaring mfor ma mclient mwith mheart mfailure mwho mdevelops mrespiratory mdistress mand
m coughs mup mpink mfrothy msputum. mWhich maction mshould mthe mnurse mtake mfirst? mA.Draw marterial
m blood mgases. m
B.Notify mthe mprimary mhealth mcare mprovider. m
C.Position min ma mhigh mFowler's mposition mwith mthe mlegs mdown. m
D.Obtain ma mchest mX-ray. m- mCORRECT mANSWER m-C m
Rationale: m
Positioning mthe mpatient min ma mhigh mFowler's mposition mwith mdangling mfeet mwill mdecrease mfurther mvenous
mreturn mto mthe mleft mventricle m(C). mThe mother mactions mshould mbe mperformed mafter mthe mchange min
mposition m(A, mB, mand mD). m
m
A mclient mwho mis mprescribed mchlorpromazine mHCl m(Thorazine) mfor mschizophrenia mdevelops mrigidity, ma
mshuffling mgait, mand mtremors. mWhich maction mby mthe mnurse mis mmost mimportant?A.Administer ma mdose mof
mbenztropine mmesylate m(Cogentin) mPRN. m
, B.Determine mif mthe mclient mhas mincreased mphotosensitivity. m
C.Provide mcomfort mmeasures mfor msore mmuscles. m
D.Assess mthe mclient mfor mvisual mand mauditory mhallucinations. m- mCORRECT mANSWER m-A m
Rationale: m
Rigidity, mshuffling mgait, mpill-rolling mhand mmovements, mtremors, mdyskinesia, mand mmasklike mface mare
mextrapyramidal mside meffects massociated mwith mThorazine. mIt mis mmost mimportant mfor mthe mnurse mto
madminister man manticholinergic msuch mas mCogentin mto mreverse mthese meffects m(A). mThe mothers m(B, mC, mD)
mmay mbe mappropriate minterventions mbut mare mnot mas murgent mas m(A). m
m
A mnurse mis minterviewing ma mmother mduring ma mwell-child mvisit. mWhich mfinding mwould malert mthe mnurse
mto mcontinue mfurther massessment mof mthe minfant? m
A.Two-month-old mwho mis munable mto mroll mfrom mback mto mabdomen m
B.Ten-month-old mwho mcannot msit mwithout msupport m
C.Nine-month-old mwho mcries mwhen mhis mmother mleaves mthe mroom m
D.Eight-month-old mwho mhas mnot myet mbegun mto mspeak mwords m- mCORRECT mANSWER m-B m
Rationale: m
As ma mdevelopmental mmilestone, minfants mshould msit munsupported mby m8 mmonths m(B). mThe mmilestone mof
mrolling mover mis machieved mat m5 mto m6 mmonths mfor mmost minfants m(A). mStranger manxiety mis mcommon mfrom
m7 mto m9 mmonths m(C). mSpeaking ma mfew mwords mis mexpected mat mabout m12 mmonths m(D). m
m
Which mintervention mshould mbe mincluded min mthe mplan mof mcare mfor ma mclient madmitted mto mthe mhospital
mwith mulcerative mcolitis? m
A.Administer mstool msofteners. m
B.Place mthe mclient mon mfluid mrestriction. m
C.Provide ma mlow-residue mdiet. m
D.Add ma mmilk mproduct mto meach mmeal. m- mCORRECT mANSWER m-C m
Rationale: m
A mlow-residue mdiet m(C) mwill mhelp mdecrease msymptoms mof mdiarrhea, mwhich mare mclinical mmanifestations
mof mulcerative mcolitis. m(A, mB, mand mD) mare mcontraindicated mand mcould mworsen mthe mcondition. m
m
COMPREHENSIVE EXAM TEST
QUESTIONS AND ANSWERS
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 mB m
B.Human mpapilloma mvirus m(HPV) m
C.Varicella m
D.Meningococcal mvaccine m- mCORRECT mANSWER m-A m
Rationale: m
The mhepatitis mB mvaccination mshould mbe mgiven mto mall mnewborns mbefore mhospital mdischarge m(A). mHPV mis
mnot mrecommended muntil madolescence m(B). mVaricella mimmunization mbegins mat m12 mmonths m(C).
mMeningococcal mvaccine mis madministered mbeginning mat m2 myears m(D). m
m
The mnurse mis mcaring mfor ma mclient mon mthe mmedical munit. mWhich mtask mcan mbe mdelegated mto munlicensed
massistive mpersonnel m(UAP)? m
A.Assess mthe mneed mto mchange ma mcentral mline mdressing. m
B.Obtain ma mfingerstick mblood mglucose mlevel. m
C.Answer ma mfamily mmember's mquestions mabout mthe mclient's mplan mof mcare. m
D.Teach mthe mclient mside meffects mto mreport mrelated mto mthe mcurrent mmedication mregimen. m- mCORRECT
mANSWER m-B m
Rationale: m
Obtaining ma mfingerstick mblood mglucose mlevel mis ma msimple mtreatment mand mis man mappropriate mskill mfor
mUAP mto mperform m(B). m(A, mC, mand mD) mare mskills mthat mcannot mbe mdelegated mto mUAP. m
m
The mnurse mis mcaring mfor ma mclient mwith man mischemic mstroke mwho mhas ma mprescription mfor mtissue
m plasminogen mactivator m(t-PA) mIV. mWhich maction(s) mshould mthe mnurse mexpect mto mimplement? m(Select
m all mthat mapply.) mA.Administer maspirin mwith mtissue mplasminogen mactivator m(t-PA). m
B.Complete mthe mNational mInstitute mof mHealth mStroke mScale m(NIHSS). m
C.Assess mthe mclient mfor msigns mof mbleeding mduring mand mafter mthe minfusion. m
D.Start mt-PA mwithin m6 mhours mafter mthe monset mof mstroke msymptoms. m
E.Initiate mmultidisciplinary mconsult mfor mpotential mrehabilitation. m- mCORRECT mANSWER m-B,C,E m
Rationale: m
,Neurologic massessment, mincluding mthe mNIHSS, mis mindicated mfor mthe mclient mreceiving mt-PA. mThis
mincludes mclose mmonitoring mfor mbleeding mduring mand mafter mthe minfusion; mif mbleeding mor mother msigns
mof mneurologic mimpairment moccur, mthe minfusion mshould mbe mstopped m(B, mC, mand mE). mAspirin mis
mcontraindicated mwith mt-PA mbecause mit mincreases mthe mrisk mfor mbleeding m(A). mThe madministration mof mt-
PA mwithin m6 mhours mof msymptoms mis mconcurrent mwith ma mdiagnosis mof ma mmyocardial minfarction mand
mwithin m4.5 mhours mof msymptoms mis mconcurrent mfor ma mstroke m(D). m
m
When mcaring mfor ma mclient min mlabor, mwhich mfinding mis mmost mimportant mto mreport mto mthe mprimary
mhealth mcare mprovider? m
A.Maternal mheart mrate, m90 mbeats/min. m
B.Fetal mheart mrate, m100 mbeats/min m
C.Maternal mblood mpressure, m140/86 mmm mHg m
D.Maternal mtemperature, m100.0° mF m- mCORRECT mANSWER m-B m
Rationale: m
A mfetal mheart mrate m(FHR) mof m100 mbeats/min mmay mindicate mfetal mdistress m(B) mbecause mthe maverage
mFHR mat mterm mis m140 mbeats/min mand mthe mnormal mrange mis m110 mto mbeats/min m160. mThe mothers m(A, mC,
mand mD) mare mnormal mfindings mfor ma mwoman min mlabor. m
m
The mnurse mis mcaring mfor ma mclient mwith mheart mfailure mwho mdevelops mrespiratory mdistress mand
m coughs mup mpink mfrothy msputum. mWhich maction mshould mthe mnurse mtake mfirst? mA.Draw marterial
m blood mgases. m
B.Notify mthe mprimary mhealth mcare mprovider. m
C.Position min ma mhigh mFowler's mposition mwith mthe mlegs mdown. m
D.Obtain ma mchest mX-ray. m- mCORRECT mANSWER m-C m
Rationale: m
Positioning mthe mpatient min ma mhigh mFowler's mposition mwith mdangling mfeet mwill mdecrease mfurther mvenous
mreturn mto mthe mleft mventricle m(C). mThe mother mactions mshould mbe mperformed mafter mthe mchange min
mposition m(A, mB, mand mD). m
m
A mclient mwho mis mprescribed mchlorpromazine mHCl m(Thorazine) mfor mschizophrenia mdevelops mrigidity, ma
mshuffling mgait, mand mtremors. mWhich maction mby mthe mnurse mis mmost mimportant?A.Administer ma mdose mof
mbenztropine mmesylate m(Cogentin) mPRN. m
, B.Determine mif mthe mclient mhas mincreased mphotosensitivity. m
C.Provide mcomfort mmeasures mfor msore mmuscles. m
D.Assess mthe mclient mfor mvisual mand mauditory mhallucinations. m- mCORRECT mANSWER m-A m
Rationale: m
Rigidity, mshuffling mgait, mpill-rolling mhand mmovements, mtremors, mdyskinesia, mand mmasklike mface mare
mextrapyramidal mside meffects massociated mwith mThorazine. mIt mis mmost mimportant mfor mthe mnurse mto
madminister man manticholinergic msuch mas mCogentin mto mreverse mthese meffects m(A). mThe mothers m(B, mC, mD)
mmay mbe mappropriate minterventions mbut mare mnot mas murgent mas m(A). m
m
A mnurse mis minterviewing ma mmother mduring ma mwell-child mvisit. mWhich mfinding mwould malert mthe mnurse
mto mcontinue mfurther massessment mof mthe minfant? m
A.Two-month-old mwho mis munable mto mroll mfrom mback mto mabdomen m
B.Ten-month-old mwho mcannot msit mwithout msupport m
C.Nine-month-old mwho mcries mwhen mhis mmother mleaves mthe mroom m
D.Eight-month-old mwho mhas mnot myet mbegun mto mspeak mwords m- mCORRECT mANSWER m-B m
Rationale: m
As ma mdevelopmental mmilestone, minfants mshould msit munsupported mby m8 mmonths m(B). mThe mmilestone mof
mrolling mover mis machieved mat m5 mto m6 mmonths mfor mmost minfants m(A). mStranger manxiety mis mcommon mfrom
m7 mto m9 mmonths m(C). mSpeaking ma mfew mwords mis mexpected mat mabout m12 mmonths m(D). m
m
Which mintervention mshould mbe mincluded min mthe mplan mof mcare mfor ma mclient madmitted mto mthe mhospital
mwith mulcerative mcolitis? m
A.Administer mstool msofteners. m
B.Place mthe mclient mon mfluid mrestriction. m
C.Provide ma mlow-residue mdiet. m
D.Add ma mmilk mproduct mto meach mmeal. m- mCORRECT mANSWER m-C m
Rationale: m
A mlow-residue mdiet m(C) mwill mhelp mdecrease msymptoms mof mdiarrhea, mwhich mare mclinical mmanifestations
mof mulcerative mcolitis. m(A, mB, mand mD) mare mcontraindicated mand mcould mworsen mthe mcondition. m
m
