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B Evolve Practice
Questions 2026 | Q&A with
Rationales
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Updated 2026 Questions and Answers
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Rationales
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,The nurse is caring for a client on the medical unit. Which B
task can be delegated to unlicensed assistive personnel Rationale:
(UAP)? Obtaining a fingerstick blood glucose level is a simple treatment and is an
A.Assess the need to change a central line dressing. appropriate skill for UAP to perform (B). (A, C, and D) are skills that cannot be
B.Obtain a fingerstick blood glucose level. delegated to UAP.
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.
The nurse is caring for a client with an ischemic stroke B,C,E
who has a prescription for tissue plasminogen activator Rationale:
(t-PA) IV. Which action(s) should the nurse expect to Neurologic assessment, including the NIHSS, is indicated for the client receiving
implement? (Select all that apply.) t-PA. This includes close monitoring for bleeding during and after the infusion; if
A.Administer aspirin with tissue plasminogen activator (t- bleeding or other signs of neurologic impairment occur, the infusion should be
PA). stopped (B, C, and E). Aspirin is contraindicated with t-PA because it increases the
B.Complete the National Institute of Health Stroke Scale risk for bleeding (A). The administration of t-PA within 6 hours of symptoms is
(NIHSS). concurrent with a diagnosis of a myocardial infarction and within 4.5 hours of
C.Assess the client for signs of bleeding during and after symptoms is concurrent for a stroke (D).
the infusion.
D.Start t-PA within 6 hours after the onset of stroke
symptoms.
E.Initiate multidisciplinary consult for potential
rehabilitation.
When caring for a client in labor, which finding is most B
important to report to the primary health care provider? Rationale:
A.Maternal heart rate, 90 beats/min. A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress (B) because
B.Fetal heart rate, 100 beats/min the average FHR at term is 140 beats/min and the normal range is 110 to beats/min
C.Maternal blood pressure, 140/86 mm Hg 160. The others (A, C, and D) are normal findings for a woman in labor.
D.Maternal temperature, 100.0° F
The nurse is caring for a client with heart failure who C
develops respiratory distress and coughs up pink frothy Rationale:
sputum. Which action should the nurse take first? Positioning the patient in a high Fowler's position with dangling feet will decrease
A.Draw arterial blood gases. further venous return to the left ventricle (C). The other actions should be
B.Notify the primary health care provider. performed after the change in position (A, B, and D).
C.Position in a high Fowler's position with the legs down.
D.Obtain a chest X-ray.
A client who is prescribed chlorpromazine HCl A
(Thorazine) for schizophrenia develops rigidity, a shuffling Rationale:
gait, and tremors. Which action by the nurse is most Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and
important?A.Administer a dose of benztropine mesylate masklike face are extrapyramidal side effects associated with Thorazine. It is most
(Cogentin) PRN. important for the nurse to administer an anticholinergic such as Cogentin to
B.Determine if the client has increased photosensitivity. reverse these effects (A). The others (B, C, D) may be appropriate interventions
C.Provide comfort measures for sore muscles. but are not as urgent as (A).
D.Assess the client for visual and auditory hallucinations.
, A nurse is interviewing a mother during a well-child visit. B
Which finding would alert the nurse to continue further Rationale:
assessment of the infant? As a developmental milestone, infants should sit unsupported by 8 months (B).
A.Two-month-old who is unable to roll from back to The milestone of rolling over is achieved at 5 to 6 months for most infants (A).
abdomen Stranger anxiety is common from 7 to 9 months (C). Speaking a few words is
B.Ten-month-old who cannot sit without support expected at about 12 months (D).
C.Nine-month-old who cries when his mother leaves the
room
D.Eight-month-old who has not yet begun to speak
words
Which intervention should be included in the plan of care C
for a client admitted to the hospital with ulcerative Rationale:
colitis? A low-residue diet (C) will help decrease symptoms of diarrhea, which are clinical
A.Administer stool softeners. manifestations of ulcerative colitis. (A, B, and D) are contraindicated and could
B.Place the client on fluid restriction. worsen the condition.
C.Provide a low-residue diet.
D.Add a milk product to each meal.
The nurse is caring for a client with deep vein thrombosis D
who is on a continuous IV heparin infusion. The activated Rationale:
partial prothrombin time (aPTT) is 120 seconds. Which An aPTT more than 100 seconds is a critically high value; therefore, the heparin
action should the nurse take? should be stopped. The antidote for heparin is protamine sulfate (D). Increasing
A.Increase the rate of the heparin infusion using a the rate would increase the risk for hemorrhage (A). The infusion should be
nomogram. stopped, and vitamin K is the antidote for warfarin (Coumadin) (B). Keeping the
B.Decrease the heparin infusion rate and give vitamin K infusion at the current rate would increase the risk for hemorrhage (C).
IM.
C.Continue the heparin infusion at the current prescribed
rate.
D.Stop the heparin drip and prepare to administer
protamine sulfate.
While assessing a client with recurring chest pain, the unit C
secretary notifies the nurse that the client's health care Rationale:
provider is on the telephone. What action should the Another nurse should be asked to take the phone call (C), which allows the nurse
nurse instruct the unit secretary to implement? to stay at the bedside to complete the assessment of the client's chest pain. (A
A.Transfer the call into the room of the client. and B) should not be done during an acute change in the client's condition.
B.Instruct the secretary to explain reason for the call. Requesting the health care provider (D) to come to the unit is premature until the
C.Ask another nurse to take the phone call. nurse completes assessment of the client's status.
D.Ask the health care provider to see the client on the
unit.
B Evolve Practice
Questions 2026 | Q&A with
Rationales
| Graded A+ | Guaranteed
success|
Updated 2026 Questions and Answers
100% Verified Exam Prep and Comprehensive
Rationales
Included
,The nurse is caring for a client on the medical unit. Which B
task can be delegated to unlicensed assistive personnel Rationale:
(UAP)? Obtaining a fingerstick blood glucose level is a simple treatment and is an
A.Assess the need to change a central line dressing. appropriate skill for UAP to perform (B). (A, C, and D) are skills that cannot be
B.Obtain a fingerstick blood glucose level. delegated to UAP.
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.
The nurse is caring for a client with an ischemic stroke B,C,E
who has a prescription for tissue plasminogen activator Rationale:
(t-PA) IV. Which action(s) should the nurse expect to Neurologic assessment, including the NIHSS, is indicated for the client receiving
implement? (Select all that apply.) t-PA. This includes close monitoring for bleeding during and after the infusion; if
A.Administer aspirin with tissue plasminogen activator (t- bleeding or other signs of neurologic impairment occur, the infusion should be
PA). stopped (B, C, and E). Aspirin is contraindicated with t-PA because it increases the
B.Complete the National Institute of Health Stroke Scale risk for bleeding (A). The administration of t-PA within 6 hours of symptoms is
(NIHSS). concurrent with a diagnosis of a myocardial infarction and within 4.5 hours of
C.Assess the client for signs of bleeding during and after symptoms is concurrent for a stroke (D).
the infusion.
D.Start t-PA within 6 hours after the onset of stroke
symptoms.
E.Initiate multidisciplinary consult for potential
rehabilitation.
When caring for a client in labor, which finding is most B
important to report to the primary health care provider? Rationale:
A.Maternal heart rate, 90 beats/min. A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress (B) because
B.Fetal heart rate, 100 beats/min the average FHR at term is 140 beats/min and the normal range is 110 to beats/min
C.Maternal blood pressure, 140/86 mm Hg 160. The others (A, C, and D) are normal findings for a woman in labor.
D.Maternal temperature, 100.0° F
The nurse is caring for a client with heart failure who C
develops respiratory distress and coughs up pink frothy Rationale:
sputum. Which action should the nurse take first? Positioning the patient in a high Fowler's position with dangling feet will decrease
A.Draw arterial blood gases. further venous return to the left ventricle (C). The other actions should be
B.Notify the primary health care provider. performed after the change in position (A, B, and D).
C.Position in a high Fowler's position with the legs down.
D.Obtain a chest X-ray.
A client who is prescribed chlorpromazine HCl A
(Thorazine) for schizophrenia develops rigidity, a shuffling Rationale:
gait, and tremors. Which action by the nurse is most Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and
important?A.Administer a dose of benztropine mesylate masklike face are extrapyramidal side effects associated with Thorazine. It is most
(Cogentin) PRN. important for the nurse to administer an anticholinergic such as Cogentin to
B.Determine if the client has increased photosensitivity. reverse these effects (A). The others (B, C, D) may be appropriate interventions
C.Provide comfort measures for sore muscles. but are not as urgent as (A).
D.Assess the client for visual and auditory hallucinations.
, A nurse is interviewing a mother during a well-child visit. B
Which finding would alert the nurse to continue further Rationale:
assessment of the infant? As a developmental milestone, infants should sit unsupported by 8 months (B).
A.Two-month-old who is unable to roll from back to The milestone of rolling over is achieved at 5 to 6 months for most infants (A).
abdomen Stranger anxiety is common from 7 to 9 months (C). Speaking a few words is
B.Ten-month-old who cannot sit without support expected at about 12 months (D).
C.Nine-month-old who cries when his mother leaves the
room
D.Eight-month-old who has not yet begun to speak
words
Which intervention should be included in the plan of care C
for a client admitted to the hospital with ulcerative Rationale:
colitis? A low-residue diet (C) will help decrease symptoms of diarrhea, which are clinical
A.Administer stool softeners. manifestations of ulcerative colitis. (A, B, and D) are contraindicated and could
B.Place the client on fluid restriction. worsen the condition.
C.Provide a low-residue diet.
D.Add a milk product to each meal.
The nurse is caring for a client with deep vein thrombosis D
who is on a continuous IV heparin infusion. The activated Rationale:
partial prothrombin time (aPTT) is 120 seconds. Which An aPTT more than 100 seconds is a critically high value; therefore, the heparin
action should the nurse take? should be stopped. The antidote for heparin is protamine sulfate (D). Increasing
A.Increase the rate of the heparin infusion using a the rate would increase the risk for hemorrhage (A). The infusion should be
nomogram. stopped, and vitamin K is the antidote for warfarin (Coumadin) (B). Keeping the
B.Decrease the heparin infusion rate and give vitamin K infusion at the current rate would increase the risk for hemorrhage (C).
IM.
C.Continue the heparin infusion at the current prescribed
rate.
D.Stop the heparin drip and prepare to administer
protamine sulfate.
While assessing a client with recurring chest pain, the unit C
secretary notifies the nurse that the client's health care Rationale:
provider is on the telephone. What action should the Another nurse should be asked to take the phone call (C), which allows the nurse
nurse instruct the unit secretary to implement? to stay at the bedside to complete the assessment of the client's chest pain. (A
A.Transfer the call into the room of the client. and B) should not be done during an acute change in the client's condition.
B.Instruct the secretary to explain reason for the call. Requesting the health care provider (D) to come to the unit is premature until the
C.Ask another nurse to take the phone call. nurse completes assessment of the client's status.
D.Ask the health care provider to see the client on the
unit.
