EXIT HESI COMPREHENSIVE B EVOLVE FINAL EXAM
QUESTIONS & CORRECT ANSWERS NEW VERSION
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). -
CORRECT ANSWER >>>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). -
CORRECT ANSWER >>>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
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,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). - CORRECT ANSWER >>>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. - CORRECT
ANSWER >>>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
tPA 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). - CORRECT ANSWER >>>The nurse
is caring for a client with an ischemic stroke who has a prescription for tissue plasminogen
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,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. - CORRECT ANSWER >>>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). - CORRECT ANSWER >>>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.
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, 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). - CORRECT ANSWER >>>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). - CORRECT ANSWER
>>>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:
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QUESTIONS & CORRECT ANSWERS NEW VERSION
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). -
CORRECT ANSWER >>>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). -
CORRECT ANSWER >>>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
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,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). - CORRECT ANSWER >>>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. - CORRECT
ANSWER >>>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
tPA 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). - CORRECT ANSWER >>>The nurse
is caring for a client with an ischemic stroke who has a prescription for tissue plasminogen
2|Page
,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. - CORRECT ANSWER >>>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). - CORRECT ANSWER >>>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.
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, 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). - CORRECT ANSWER >>>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). - CORRECT ANSWER
>>>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:
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