EXIT HESI Comprehensive HESI RN EXIT EXAM 2024-2026 150 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) |ALREADY GRADED A+
Evolve Practice Questions
The nurse is caring f̣or a client with a cerebrovascular accident (CVA) who is receiving enteral tube
f̣eedings. Which task perf̣ormed by the UAP requires immediate intervention by the nurse?
A.Suctions oral secretions f̣rom mouth
B.Positions head of̣ bed f̣lat when changing sheets
C.Takes temperature using the axillary method
D.Keeps head of̣ bed elevated at 30 degrees - ANSWERB
Rationale:
Positioning the head of̣ the bed f̣lat when enteral f̣eedings are in progress puts the client at risk f̣or
aspiration (B). The others are all acceptable tasks per f̣ormed by the UAP (A, C, and D).
When caring f̣or a postsurgical client who has undergone multiple blood trans f̣usions, which serum
laboratory f̣inding is of̣ 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 - ANSWERB
Rationale:
Multiple blood transf̣usions are a risk f̣actor f̣or hyperkalemia. A serum potassium level higher than 5.0
mEq/L indicates hyperkalemia (B). The others are normal f̣indings (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 - ANSWERA
Rationale:
The hepatitis B vaccination should be given to all newborns be f̣ore 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 f̣or 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 f̣ingerstick blood glucose level.
C.Answer a f̣amily member's questions about the client's plan o f̣ care.
D.Teach the client side ef̣fects
̣ to report related to the current medication regimen. - ANSWERB
Rationale:
Obtaining a f̣ingerstick blood glucose level is a simple treatment and is an appropriate skill f̣or UAP to
perf̣orm (B). (A, C, and D) are skills that cannot be delegated to UAP.
The nurse is caring f̣or a client with an ischemic stroke who has a prescription f̣or 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 of̣ Health Stroke Scale (NIHSS).
C.Assess the client f̣or signs of̣ bleeding during and af̣ter the in f̣usion.
D.Start t-PA within 6 hours af̣ter the onset of̣ stroke symptoms.
E.Initiate multidisciplinary consult f̣or potential rehabilitation. - ANSWERB,C,E
Rationale:
Neurologic assessment, including the NIHSS, is indicated f̣or the client receiving t-PA. This includes
close monitoring f̣or bleeding during and a f̣ter the inf̣usion; i f̣ bleeding or other signs o f̣ neurologic
impairment occur, the inf̣usion should be stopped (B, C, and E). Aspirin is contraindicated with t-PA
because it increases the risk f̣or bleeding (A). The administration o f̣ t-PA within 6 hours o f̣ symptoms is
,concurrent with a diagnosis of̣ a myocardial in f̣arction and within 4.5 hours o f̣ symptoms is concurrent
f̣or a stroke (D).
When caring f̣or a client in labor, which f̣inding 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 - ANSWERB
Rationale:
A f̣etal heart rate (FHR) of̣ 100 beats/min may indicate f̣etal 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 f̣indings f̣or a woman in labor.
The nurse is caring f̣or a client with heart f̣ailure who develops respiratory distress and coughs up pink
f̣rothy sputum. Which action should the nurse take f̣irst?
A.Draw arterial blood gases.
B.Notif̣y the primary health care provider.
C.Position in a high Fowler's position with the legs down.
D.Obtain a chest X-ray. - ANSWERC
Rationale:
Positioning the patient in a high Fowler's position with dangling f̣eet will decrease f̣urther venous return
to the lef̣t ventricle (C). The other actions should be per f̣ormed a f̣ter the change in position (A, B, and D).
A client who is prescribed chlorpromazine HCl (Thorazine) f̣or schizophrenia develops rigidity, a shu f̣fling
̣
gait, and tremors. Which action by the nurse is most important?A.Administer a dose o f̣ benztropine
mesylate (Cogentin) PRN.
B.Determine if̣ the client has increased photosensitivity.
C.Provide comf̣ort measures f̣or sore muscles.
, D.Assess the client f̣or visual and auditory hallucinations. - ANSWERA
Rationale:
Rigidity, shuf̣fling
̣ gait, pill-rolling hand movements, tremors, dyskinesia, and masklike f̣ace are
extrapyramidal side ef̣fects
̣ associated with Thorazine. It is most important f̣or the nurse to administer
an anticholinergic such as Cogentin to reverse these e f̣fects
̣ (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 f̣inding would alert the nurse to
continue f̣urther assessment of̣ the inf̣ant?
A.Two-month-old who is unable to roll f̣rom 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 - ANSWERB
Rationale:
As a developmental milestone, inf̣ants should sit unsupported by 8 months (B). The milestone o f̣ rolling
over is achieved at 5 to 6 months f̣or most in f̣ants (A). Stranger anxiety is common f̣rom 7 to 9 months
(C). Speaking a f̣ew words is expected at about 12 months (D).
Which intervention should be included in the plan o f̣ care f̣or a client admitted to the hospital with
ulcerative colitis?
A.Administer stool sof̣teners.
B.Place the client on f̣luid restriction.
C.Provide a low-residue diet.
D.Add a milk product to each meal. - ANSWERC
Rationale:
A low-residue diet (C) will help decrease symptoms of̣ diarrhea, which are clinical mani f̣estations o f̣
ulcerative colitis. (A, B, and D) are contraindicated and could worsen the condition.
AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) |ALREADY GRADED A+
Evolve Practice Questions
The nurse is caring f̣or a client with a cerebrovascular accident (CVA) who is receiving enteral tube
f̣eedings. Which task perf̣ormed by the UAP requires immediate intervention by the nurse?
A.Suctions oral secretions f̣rom mouth
B.Positions head of̣ bed f̣lat when changing sheets
C.Takes temperature using the axillary method
D.Keeps head of̣ bed elevated at 30 degrees - ANSWERB
Rationale:
Positioning the head of̣ the bed f̣lat when enteral f̣eedings are in progress puts the client at risk f̣or
aspiration (B). The others are all acceptable tasks per f̣ormed by the UAP (A, C, and D).
When caring f̣or a postsurgical client who has undergone multiple blood trans f̣usions, which serum
laboratory f̣inding is of̣ 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 - ANSWERB
Rationale:
Multiple blood transf̣usions are a risk f̣actor f̣or hyperkalemia. A serum potassium level higher than 5.0
mEq/L indicates hyperkalemia (B). The others are normal f̣indings (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 - ANSWERA
Rationale:
The hepatitis B vaccination should be given to all newborns be f̣ore 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 f̣or 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 f̣ingerstick blood glucose level.
C.Answer a f̣amily member's questions about the client's plan o f̣ care.
D.Teach the client side ef̣fects
̣ to report related to the current medication regimen. - ANSWERB
Rationale:
Obtaining a f̣ingerstick blood glucose level is a simple treatment and is an appropriate skill f̣or UAP to
perf̣orm (B). (A, C, and D) are skills that cannot be delegated to UAP.
The nurse is caring f̣or a client with an ischemic stroke who has a prescription f̣or 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 of̣ Health Stroke Scale (NIHSS).
C.Assess the client f̣or signs of̣ bleeding during and af̣ter the in f̣usion.
D.Start t-PA within 6 hours af̣ter the onset of̣ stroke symptoms.
E.Initiate multidisciplinary consult f̣or potential rehabilitation. - ANSWERB,C,E
Rationale:
Neurologic assessment, including the NIHSS, is indicated f̣or the client receiving t-PA. This includes
close monitoring f̣or bleeding during and a f̣ter the inf̣usion; i f̣ bleeding or other signs o f̣ neurologic
impairment occur, the inf̣usion should be stopped (B, C, and E). Aspirin is contraindicated with t-PA
because it increases the risk f̣or bleeding (A). The administration o f̣ t-PA within 6 hours o f̣ symptoms is
,concurrent with a diagnosis of̣ a myocardial in f̣arction and within 4.5 hours o f̣ symptoms is concurrent
f̣or a stroke (D).
When caring f̣or a client in labor, which f̣inding 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 - ANSWERB
Rationale:
A f̣etal heart rate (FHR) of̣ 100 beats/min may indicate f̣etal 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 f̣indings f̣or a woman in labor.
The nurse is caring f̣or a client with heart f̣ailure who develops respiratory distress and coughs up pink
f̣rothy sputum. Which action should the nurse take f̣irst?
A.Draw arterial blood gases.
B.Notif̣y the primary health care provider.
C.Position in a high Fowler's position with the legs down.
D.Obtain a chest X-ray. - ANSWERC
Rationale:
Positioning the patient in a high Fowler's position with dangling f̣eet will decrease f̣urther venous return
to the lef̣t ventricle (C). The other actions should be per f̣ormed a f̣ter the change in position (A, B, and D).
A client who is prescribed chlorpromazine HCl (Thorazine) f̣or schizophrenia develops rigidity, a shu f̣fling
̣
gait, and tremors. Which action by the nurse is most important?A.Administer a dose o f̣ benztropine
mesylate (Cogentin) PRN.
B.Determine if̣ the client has increased photosensitivity.
C.Provide comf̣ort measures f̣or sore muscles.
, D.Assess the client f̣or visual and auditory hallucinations. - ANSWERA
Rationale:
Rigidity, shuf̣fling
̣ gait, pill-rolling hand movements, tremors, dyskinesia, and masklike f̣ace are
extrapyramidal side ef̣fects
̣ associated with Thorazine. It is most important f̣or the nurse to administer
an anticholinergic such as Cogentin to reverse these e f̣fects
̣ (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 f̣inding would alert the nurse to
continue f̣urther assessment of̣ the inf̣ant?
A.Two-month-old who is unable to roll f̣rom 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 - ANSWERB
Rationale:
As a developmental milestone, inf̣ants should sit unsupported by 8 months (B). The milestone o f̣ rolling
over is achieved at 5 to 6 months f̣or most in f̣ants (A). Stranger anxiety is common f̣rom 7 to 9 months
(C). Speaking a f̣ew words is expected at about 12 months (D).
Which intervention should be included in the plan o f̣ care f̣or a client admitted to the hospital with
ulcerative colitis?
A.Administer stool sof̣teners.
B.Place the client on f̣luid restriction.
C.Provide a low-residue diet.
D.Add a milk product to each meal. - ANSWERC
Rationale:
A low-residue diet (C) will help decrease symptoms of̣ diarrhea, which are clinical mani f̣estations o f̣
ulcerative colitis. (A, B, and D) are contraindicated and could worsen the condition.
