EXIT HESI Comprehensive B Evolve
(100 Practice 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 ✔️Ans - 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 ✔️Ans - 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 ✔️Ans - 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).
,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. ✔️Ans - 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.)
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. ✔️Ans -
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.
B.Fetal heart rate, 100 beats/min
C.Maternal blood pressure, 140/86 mm Hg
D.Maternal temperature, 100.0° F ✔️Ans - 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.
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. ✔️Ans - 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).
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. ✔️Ans - 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).
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 ✔️Ans - 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).
, 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. ✔️Ans - 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.
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 action should the nurse take?
A.Increase the rate of the heparin infusion using a nomogram.
B.Decrease the heparin infusion rate and give vitamin K IM.
C.Continue the heparin infusion at the current prescribed rate.
D.Stop the heparin drip and prepare to administer protamine sulfate.
✔️Ans - D
Rationale:
An aPTT more than 100 seconds is a critically high value; therefore, the
heparin should be stopped. The antidote for heparin is protamine sulfate (D).
Increasing the rate would increase the risk for hemorrhage (A). The infusion
should be stopped, and vitamin K is the antidote for warfarin (Coumadin) (B).
Keeping the infusion at the current rate would increase the risk for
hemorrhage (C).
While assessing a client with recurring chest pain, the unit secretary notifies
the nurse that the client's health care provider is on the telephone. What
action should the nurse instruct the unit secretary to implement?
A.Transfer the call into the room of the client.
B.Instruct the secretary to explain reason for the call.
C.Ask another nurse to take the phone call.
D.Ask the health care provider to see the client on the unit. ✔️Ans - C
Rationale:
Another nurse should be asked to take the phone call (C), which allows the
nurse to stay at the bedside to complete the assessment of the client's chest
pain. (A and B) should not be done during an acute change in the client's
(100 Practice 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 ✔️Ans - 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 ✔️Ans - 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 ✔️Ans - 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).
,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. ✔️Ans - 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.)
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. ✔️Ans -
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.
B.Fetal heart rate, 100 beats/min
C.Maternal blood pressure, 140/86 mm Hg
D.Maternal temperature, 100.0° F ✔️Ans - 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.
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. ✔️Ans - 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).
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. ✔️Ans - 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).
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 ✔️Ans - 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).
, 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. ✔️Ans - 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.
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 action should the nurse take?
A.Increase the rate of the heparin infusion using a nomogram.
B.Decrease the heparin infusion rate and give vitamin K IM.
C.Continue the heparin infusion at the current prescribed rate.
D.Stop the heparin drip and prepare to administer protamine sulfate.
✔️Ans - D
Rationale:
An aPTT more than 100 seconds is a critically high value; therefore, the
heparin should be stopped. The antidote for heparin is protamine sulfate (D).
Increasing the rate would increase the risk for hemorrhage (A). The infusion
should be stopped, and vitamin K is the antidote for warfarin (Coumadin) (B).
Keeping the infusion at the current rate would increase the risk for
hemorrhage (C).
While assessing a client with recurring chest pain, the unit secretary notifies
the nurse that the client's health care provider is on the telephone. What
action should the nurse instruct the unit secretary to implement?
A.Transfer the call into the room of the client.
B.Instruct the secretary to explain reason for the call.
C.Ask another nurse to take the phone call.
D.Ask the health care provider to see the client on the unit. ✔️Ans - C
Rationale:
Another nurse should be asked to take the phone call (C), which allows the
nurse to stay at the bedside to complete the assessment of the client's chest
pain. (A and B) should not be done during an acute change in the client's
