EXIT HESI Evolve Vomprehensive B Exam 100 Questions And Correct
Verified Answers New Updated Version
The nurse is caring for a client with a B
cerebrovascular accident (CVA) who is Rationale:
receiving enteral tube feedings. Which task Positioning the head of the bed flat when enteral feedings are in
performed by the UAP requires immediate progress puts the client at risk for aspiration (B). The others are all
intervention by the nurse? acceptable tasks performed by the UJAP (A, C, and D).
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
,When caring for a postsurgical client who has B
undergone multiple blood Rationale:
transfusions,which serum laboratory finding Multiple blood transfusions are a risk factor for hyperkalemia.
is of most concern to the nurse? A serum potassium level higher than 5.0 mEq/L indicates
A.Soddium level, 137 mEq/L hyperkalemia (B). The others are normal findings (A, C, and D).
B.Potassium level, 5.5 mEq/L
C.Blood urea nitrogen (BUN) level, 18 mg/dL
D.Calcium level, 10 mEq/L
Which vaccination should the nurse A
administer to a newborn? Rationale:
A.Hepatitis B The hepatitis B vaccination should be given to all newborns
B.Human papilloma virus (HPV) before hospital discharge (A). HPV is not recommended until
C.Varicella adolescence (B). Varicella immunization begins at 12 months
(C). Meningococcal vaccine is administered beginning at
D.Meningococcal vaccine
2years (D).
The nurse is caring for a client on the B
medical unit. Which task can be delegated to Rationale:
unlicensed assistive personnel (UAP)? Obtaining a fingerstick blood glucose level is a simple
A.Assess the need to change a central line treatment and is an appropriate skill for UAP to perform (B).
dressing. (A, C, and D) are skills that cannot be delegated to UAP.
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.
The nurse is caring for a client with an B,C,E
ischemic stroke who has a prescription for Rationale:
tissue plasminogen activator (t-PA) IV. Which Neurologic assessment, including the NIHSS, is indicated for the
action(s) should the nurse expect to client receiving t-PA. This includes close monitoring for bleeding
implement? (Select all that apply.)A.Administer during and after the infusion; if bleeding or other signs of
aspirin with tissue plasminogen activator (t-PA). neurologic impairment occur, the infusion should be stopped (B,
B.Complete the National Institute of Health C, and E). Aspirin is contraindicated with t-PA because it
Stroke Scale (NIHSS). increases the risk for bleeding (A).The
C.Assess the client for signs of bleeding administration of t-PA within 6 hours of symptoms is
during and after the infusion. concurrent with a diagnosis of a mnyocardial infarction and
D.Start t-PA within 6 hours after the onset of within 4.5 hours of symptoms is concurrent for a stroke (D).
stroke symptoms.
E.Initiate multidisciplinary consult for
potential rehabilitation.
When caring for a client in labor, which B
finding is most important to report to the Rationale:
primary health care provider? A fetal heart rate (FHR) of 100 beats/min may indicate fetal
A.Maternal heart rate, 90 beats/min. distress (B) because the average FHR at term is 140 beats/min
B.Fetal heart rate, 100 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.
C.Maternal blood pressure, 140/86 mm Hg
D.Maternal temperature, 100.0° F
, The nurse is caring for a client with heart C
failure who develops respiratory distress Rationale:
and coughs up pink frothy sputum. Which Positioning the patient in a high Fowler's position with
action should the nurse take first? dangling feet will decrease further venous return to the left
A.Draw arterial blood gases. ventricle (C). The other actions should be performed after the
B.Notify the primary health care provider. change in position (A, B, and D).
C.Position in a highFowler's position with
the legs down.
D.Obtain a chest X-ray.
A client who is prescribed chlorpromazine A
HCl (Thorazine) for schizophrenia develops Rationale:
rigidity, a shuffling gait, and tremors. Which Rigidity, shuffling gait, pill-rolling hand movements,
action by the nurse is most important? tremors,dyskinesia, and masklike face are extrapyramidal side
A.Administer a dose of benztropine effects
mesylate (Cogentin) PRN. associated with Thorazine. It is most important for the nurse to
B.Determine if the client has increased administer an anticholinergic such as Cogentin to reverse these
photosensitivity. effects (A). The others (B,C, D) may be appropriate interventions
C.Provide comfort measures for sore but are not as urgent as (A).
muscles.
D.Assess the client for visual and auditory
hallucinations.
A nurse is interviewing a mother during a well- B
child visit. Which finding would alert the nurse Rationale:
to continue further assessment of the infant? As a developmental milestone, infants should sit unsupported by
A.Two-month-old who is unable to roll from 8 months (B). The milestone of rolling over is achieved at 5to 6
back to abdomen months for most infants (A). Stranger anxiety is common from 7
B.Ten-month-old who cannot sit without to 9 months (C). Speaking a few words is expected at about 12
support 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 C
the plan of care for a client admitted to the Rationale:
hospital with ulcerative colitis? A low-residue diet (C) will help decrease symptoms of
A.Administer stool softeners. diarrhea, which are clinical manifestations of ulcerative colitis.
B.Place the client on fluid restriction. (A, B, and D) are contraindicated and could worsen the
C.Provide a low-residue diet. condition.
D.Add a milk product to each meal.
Verified Answers New Updated Version
The nurse is caring for a client with a B
cerebrovascular accident (CVA) who is Rationale:
receiving enteral tube feedings. Which task Positioning the head of the bed flat when enteral feedings are in
performed by the UAP requires immediate progress puts the client at risk for aspiration (B). The others are all
intervention by the nurse? acceptable tasks performed by the UJAP (A, C, and D).
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
,When caring for a postsurgical client who has B
undergone multiple blood Rationale:
transfusions,which serum laboratory finding Multiple blood transfusions are a risk factor for hyperkalemia.
is of most concern to the nurse? A serum potassium level higher than 5.0 mEq/L indicates
A.Soddium level, 137 mEq/L hyperkalemia (B). The others are normal findings (A, C, and D).
B.Potassium level, 5.5 mEq/L
C.Blood urea nitrogen (BUN) level, 18 mg/dL
D.Calcium level, 10 mEq/L
Which vaccination should the nurse A
administer to a newborn? Rationale:
A.Hepatitis B The hepatitis B vaccination should be given to all newborns
B.Human papilloma virus (HPV) before hospital discharge (A). HPV is not recommended until
C.Varicella adolescence (B). Varicella immunization begins at 12 months
(C). Meningococcal vaccine is administered beginning at
D.Meningococcal vaccine
2years (D).
The nurse is caring for a client on the B
medical unit. Which task can be delegated to Rationale:
unlicensed assistive personnel (UAP)? Obtaining a fingerstick blood glucose level is a simple
A.Assess the need to change a central line treatment and is an appropriate skill for UAP to perform (B).
dressing. (A, C, and D) are skills that cannot be delegated to UAP.
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.
The nurse is caring for a client with an B,C,E
ischemic stroke who has a prescription for Rationale:
tissue plasminogen activator (t-PA) IV. Which Neurologic assessment, including the NIHSS, is indicated for the
action(s) should the nurse expect to client receiving t-PA. This includes close monitoring for bleeding
implement? (Select all that apply.)A.Administer during and after the infusion; if bleeding or other signs of
aspirin with tissue plasminogen activator (t-PA). neurologic impairment occur, the infusion should be stopped (B,
B.Complete the National Institute of Health C, and E). Aspirin is contraindicated with t-PA because it
Stroke Scale (NIHSS). increases the risk for bleeding (A).The
C.Assess the client for signs of bleeding administration of t-PA within 6 hours of symptoms is
during and after the infusion. concurrent with a diagnosis of a mnyocardial infarction and
D.Start t-PA within 6 hours after the onset of within 4.5 hours of symptoms is concurrent for a stroke (D).
stroke symptoms.
E.Initiate multidisciplinary consult for
potential rehabilitation.
When caring for a client in labor, which B
finding is most important to report to the Rationale:
primary health care provider? A fetal heart rate (FHR) of 100 beats/min may indicate fetal
A.Maternal heart rate, 90 beats/min. distress (B) because the average FHR at term is 140 beats/min
B.Fetal heart rate, 100 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.
C.Maternal blood pressure, 140/86 mm Hg
D.Maternal temperature, 100.0° F
, The nurse is caring for a client with heart C
failure who develops respiratory distress Rationale:
and coughs up pink frothy sputum. Which Positioning the patient in a high Fowler's position with
action should the nurse take first? dangling feet will decrease further venous return to the left
A.Draw arterial blood gases. ventricle (C). The other actions should be performed after the
B.Notify the primary health care provider. change in position (A, B, and D).
C.Position in a highFowler's position with
the legs down.
D.Obtain a chest X-ray.
A client who is prescribed chlorpromazine A
HCl (Thorazine) for schizophrenia develops Rationale:
rigidity, a shuffling gait, and tremors. Which Rigidity, shuffling gait, pill-rolling hand movements,
action by the nurse is most important? tremors,dyskinesia, and masklike face are extrapyramidal side
A.Administer a dose of benztropine effects
mesylate (Cogentin) PRN. associated with Thorazine. It is most important for the nurse to
B.Determine if the client has increased administer an anticholinergic such as Cogentin to reverse these
photosensitivity. effects (A). The others (B,C, D) may be appropriate interventions
C.Provide comfort measures for sore but are not as urgent as (A).
muscles.
D.Assess the client for visual and auditory
hallucinations.
A nurse is interviewing a mother during a well- B
child visit. Which finding would alert the nurse Rationale:
to continue further assessment of the infant? As a developmental milestone, infants should sit unsupported by
A.Two-month-old who is unable to roll from 8 months (B). The milestone of rolling over is achieved at 5to 6
back to abdomen months for most infants (A). Stranger anxiety is common from 7
B.Ten-month-old who cannot sit without to 9 months (C). Speaking a few words is expected at about 12
support 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 C
the plan of care for a client admitted to the Rationale:
hospital with ulcerative colitis? A low-residue diet (C) will help decrease symptoms of
A.Administer stool softeners. diarrhea, which are clinical manifestations of ulcerative colitis.
B.Place the client on fluid restriction. (A, B, and D) are contraindicated and could worsen the
C.Provide a low-residue diet. condition.
D.Add a milk product to each meal.
