EXIT HESI COMPREHENSIVE B EVOLVE EXAM QUESTIONS COMPLETE WITH 100% VERIFIED SOLUTIONS WITH DETAILED RATIONALES

EXIT HESI COMPREHENSIVE B EVOLVE EXAM QUESTIONS COMPLETE WITH 100% VERIFIED SOLUTIONS WITH DETAILED RATIONALES 1. The nurse is caring for a client with a new tracheostomy. Which observation requires immediate intervention? A) The client's oxygen saturation is 92% B) The tracheostomy ties are snug with one fingerbreadth of space C) The client has copious thick yellow secretions D) The inner cannula is cleaned with hydrogen peroxide E) The stoma site is pink and dry Correct Answer: A) The client's oxygen saturation is 92% Rationale: A client with a new tracheostomy should maintain oxygen saturation above 95%. An SpO2 of 92% indicates inadequate oxygenation and requires immediate assessment of airway patency, suctioning, or ventilator adjustment. The tracheostomy ties should allow one fingerbreadth, secretions may be present, and hydrogen peroxide is acceptable for cleaning the inner cannula. ________________________________________ 2. A client with chronic kidney disease has a serum phosphate level of 6.2 mg/dL. Which medication should the nurse anticipate administering? A) Calcium acetate (PhosLo) B) Ferrous sulfate C) Furosemide (Lasix) D) Sodium polystyrene sulfonate (Kayexalate) E) Sevelamer carbonate Correct Answer: A) Calcium acetate (PhosLo) Rationale: Calcium acetate is a phosphate binder that works by binding dietary phosphate in the gastrointestinal tract, preventing its absorption. Normal phosphate levels are 2.5-4.5 mg/dL. Sevelamer is another phosphate binder, but calcium acetate is the most commonly prescribed first-line agent for hyperphosphatemia in CKD. ________________________________________ 3. The nurse is preparing to administer a blood transfusion to a client. Which action is most important prior to initiating the transfusion? A) Verify the client's blood type with the blood bank B) Warm the blood product to room temperature C) Obtain signed informed consent from the client D) Prime the IV tubing with normal saline E) Document baseline vital signs Correct Answer: C) Obtain signed informed consent from the client Rationale: Informed consent is legally required before blood product administration. The client must understand the risks and benefits of the transfusion. While verifying blood type, priming tubing with normal saline, and documenting vital signs are all important, they occur after consent is obtained. ________________________________________ 4. A client is receiving morphine sulfate 4 mg IV push for severe pain. Which finding indicates an adverse effect requiring immediate action? A) Respiratory rate of 10 breaths/min B) Pain rating decreased from 8 to 3 C) Blood pressure of 110/70 mm Hg D) Heart rate of 88 beats/min E) Pupils are constricted bilaterally Correct Answer: A) Respiratory rate of 10 breaths/min Rationale: Morphine is a potent respiratory depressant. A respiratory rate below 12 breaths/min indicates respiratory depression and requires immediate intervention, including holding the medication, stimulating the client, and potentially administering naloxone (Narcan). ________________________________________ 5. The nurse is caring for a client following a thyroidectomy. Which assessment finding requires immediate notification of the healthcare provider? A) Serum calcium level of 8.0 mg/dL B) Blood pressure of 132/84 mm Hg C) Heart rate of 92 beats/min D) Temperature of 99.8°F E) The client reports tingling around the mouth Correct Answer: E) The client reports tingling around the mouth Rationale: Tingling around the mouth (circumoral paresthesia) is an early sign of hypocalcemia, which can occur after thyroidectomy if the parathyroid glands are accidentally removed or damaged. This can progress to life-threatening tetany and requires immediate calcium replacement. ________________________________________ 6. A client with COPD is receiving oxygen at 2 L/min via nasal cannula. Which assessment finding indicates the oxygen therapy is effective? A) Respiratory rate of 28 breaths/min B) Pulse oximetry reading of 92% C) Client reports increased shortness of breath D) Arterial PaCO2 of 58 mm Hg E) Heart rate of 110 beats/min Correct Answer: B) Pulse oximetry reading of 92% Rationale: For clients with COPD, oxygen saturation goals are typically 88-92% to maintain adequate oxygenation while avoiding suppression of the hypoxic drive. A reading of 92% indicates the oxygen therapy is effective and within the target range. ________________________________________ 7. The nurse is assessing a client with a diagnosis of appendicitis. Which finding is most concerning? A) Right lower quadrant pain B) Rebound tenderness C) Fever of 100.4°F D) Sudden relief of pain accompanied by tachycardia E) Nausea and vomiting Correct Answer: D) Sudden relief of pain accompanied by tachycardia Rationale: Sudden relief of pain accompanied by tachycardia in a client with appendicitis suggests perforation of the appendix, which is a medical emergency. When the appendix perforates, pressure is released causing temporary pain relief, but peritonitis quickly develops. ________________________________________ 8. The nurse is caring for a client with a chest tube. Which finding requires immediate intervention? A) Continuous bubbling in the suction control chamber B) Intermittent bubbling in the water seal chamber C) Drainage of 50 mL in the past hour D) The chest tube is disconnected from the drainage system E) The client reports pain at the insertion site Correct Answer: D) The chest tube is disconnected from the drainage system Rationale: A disconnected chest tube creates an open pneumothorax and can cause lung collapse. The nurse must immediately place the end of the chest tube in sterile water to re-establish the water seal and prevent air from entering the pleural space. ________________________________________ 9. A client with major depressive disorder is prescribed phenelzine (Nardil). Which food item should the nurse instruct the client to avoid? A) Grilled chicken B) Fresh fruits C) Aged cheese