EXIT HESI Comprehensive B Evolve
Practice Questions 2025/2026 Exam
Questions with 100% Correct Answers |
Latest Update
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).
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PRIVACY STATEMENT. ALL RIGHTS RESERVED.
,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).
Which vaccination should the nurse administer to a newborn?
A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
D.Meningococcal vaccine - 🧠 ANSWER ✔✔A
Rationale:
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PRIVACY STATEMENT. ALL RIGHTS RESERVED.
,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)?
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.
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.)
COPYRIGHT©MILATEDSOLANA 2025/2026. YEAR PUBLISHED 2025. COMPANY REGISTRATION NUMBER: 619652435. TERMS OF USE.
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PRIVACY STATEMENT. ALL RIGHTS RESERVED.
, 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 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?
A.Maternal heart rate, 90 beats/min.
COPYRIGHT©MILATEDSOLANA 2025/2026. YEAR PUBLISHED 2025. COMPANY REGISTRATION NUMBER: 619652435. TERMS OF USE.
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PRIVACY STATEMENT. ALL RIGHTS RESERVED.
Practice Questions 2025/2026 Exam
Questions with 100% Correct Answers |
Latest Update
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).
COPYRIGHT©MILATEDSOLANA 2025/2026. YEAR PUBLISHED 2025. COMPANY REGISTRATION NUMBER: 619652435. TERMS OF USE.
1
PRIVACY STATEMENT. ALL RIGHTS RESERVED.
,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).
Which vaccination should the nurse administer to a newborn?
A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
D.Meningococcal vaccine - 🧠 ANSWER ✔✔A
Rationale:
COPYRIGHT©MILATEDSOLANA 2025/2026. YEAR PUBLISHED 2025. COMPANY REGISTRATION NUMBER: 619652435. TERMS OF USE.
2
PRIVACY STATEMENT. ALL RIGHTS RESERVED.
,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)?
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.
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.)
COPYRIGHT©MILATEDSOLANA 2025/2026. YEAR PUBLISHED 2025. COMPANY REGISTRATION NUMBER: 619652435. TERMS OF USE.
3
PRIVACY STATEMENT. ALL RIGHTS RESERVED.
, 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 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?
A.Maternal heart rate, 90 beats/min.
COPYRIGHT©MILATEDSOLANA 2025/2026. YEAR PUBLISHED 2025. COMPANY REGISTRATION NUMBER: 619652435. TERMS OF USE.
4
PRIVACY STATEMENT. ALL RIGHTS RESERVED.
