EXIT HESI COMPREHENSIVE B FULL SOLUTION
STUDY GUIDE
◉ When caring for a postsurgical client who has undergone multiple
blood transfusions, which serum laboratory finding is of most
concern to the nurse?
Answer: B.Potassium level, 5.5 mEq/L
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?
Answer: A. Hepatitis B
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)?
Answer: B.Obtain a fingerstick blood glucose level.
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.)
Answer: B. Complete the National Institute of Health Stroke Scale
(NIHSS).
C. Assess the client for signs of bleeding during and after the
infusion.
E. Initiate multidisciplinary consult for potential rehabilitation.
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?
Answer: B. Fetal heart rate, 100 beats/min
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?
Answer: C. Position in a high Fowler's position with the legs down.
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).
, ◉ 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?
Answer: A. Administer a dose of benztropine mesylate (Cogentin)
PRN.
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 nurse is interviewing a mother during a well-child visit. Which
finding would alert the nurse to continue further assessment of the
infant?
Answer: B. Ten-month-old who cannot sit without support
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).
STUDY GUIDE
◉ When caring for a postsurgical client who has undergone multiple
blood transfusions, which serum laboratory finding is of most
concern to the nurse?
Answer: B.Potassium level, 5.5 mEq/L
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?
Answer: A. Hepatitis B
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)?
Answer: B.Obtain a fingerstick blood glucose level.
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.)
Answer: B. Complete the National Institute of Health Stroke Scale
(NIHSS).
C. Assess the client for signs of bleeding during and after the
infusion.
E. Initiate multidisciplinary consult for potential rehabilitation.
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?
Answer: B. Fetal heart rate, 100 beats/min
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?
Answer: C. Position in a high Fowler's position with the legs down.
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).
, ◉ 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?
Answer: A. Administer a dose of benztropine mesylate (Cogentin)
PRN.
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 nurse is interviewing a mother during a well-child visit. Which
finding would alert the nurse to continue further assessment of the
infant?
Answer: B. Ten-month-old who cannot sit without support
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).
