EXIT HESI COMPREHENSIVE B EVOLVE PRACTICE
QUESTIONS | 2026/2027 UPDATE | 150 QUESTIONS
WITH CORRECT ANSWERS AND DETAILED
RATIONALES | 100% VERIFIED
Section 1: Delegation, Prioritization, and Leadership
(Questions 1–25)
Question 1: The nurse is caring for a client with a cerebrovascular
accident (CVA) who is receiving enteral tube feedings. Which task
performed by the unlicensed assistive personnel (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
Answer: B
Rationale: Positioning the head of the bed flat when enteral feedings are in progress
puts the client at risk for aspiration. The head of the bed should be maintained at 30–45
degrees during and after enteral feedings to prevent reflux and aspiration pneumonia.
The other actions are appropriate tasks for UAP to perform.
,Question 2: 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
Answer: B
Rationale: Obtaining a fingerstick blood glucose level is a simple treatment and is an
appropriate skill for UAP to perform. Assessment (A), teaching (D), and providing
explanations about the plan of care (C) require the knowledge and judgment of a
licensed nurse and cannot be delegated to UAP.
Question 3: 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
Answer: B
Rationale: Multiple blood transfusions are a risk factor for hyperkalemia. A serum
potassium level higher than 5.0 mEq/L indicates hyperkalemia, which can cause cardiac
arrhythmias. The other values are within normal limits.
Question 4: 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
Answer: 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.
A multidisciplinary consult for rehabilitation should be initiated. Aspirin is
contraindicated with t-PA because it increases the risk for bleeding. t-PA should be
given within 4.5 hours of symptom onset for stroke.
Question 5: A client who is prescribed chlorpromazine HCl
(Thorazine) for schizophrenia develops extrapyramidal side
effects. Which intervention is most important for the nurse to
implement?
A. Administer an anticholinergic medication
B. Provide comfort measures for sore muscles
C. Assess the client for visual and auditory hallucinations
D. Evaluate the client's response to the antipsychotic
Answer: A
Rationale: Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and
masklike face are extrapyramidal side effects associated with chlorpromazine. It is most
important for the nurse to administer an anticholinergic such as Cogentin to reverse
these effects.
, Question 6: 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
Answer: C
Rationale: Another nurse should be asked to take the phone call, which allows the
nurse to stay at the bedside to complete the assessment of the client's chest pain.
Transferring the call during an acute change in condition is inappropriate.
Question 7: When blood or blood products are administered,
which task can be assigned to the licensed practical nurse (LPN)?
A. Initiation of the blood product
B. Obtaining vital signs after infusion has begun
C. Assessment of client's condition prior to blood administration
D. Evaluation of client's response after receiving blood product
Answer: B
Rationale: Blood and blood products must be initiated by the registered nurse (RN);
however, obtaining vital signs may be delegated to the LPN as long as the results are
evaluated by the RN. Assessment and evaluation are within the scope of the RN.
Question 8: The nurse is caring for a client with a cerebrovascular
accident (CVA) who is receiving enteral tube feedings. Which
QUESTIONS | 2026/2027 UPDATE | 150 QUESTIONS
WITH CORRECT ANSWERS AND DETAILED
RATIONALES | 100% VERIFIED
Section 1: Delegation, Prioritization, and Leadership
(Questions 1–25)
Question 1: The nurse is caring for a client with a cerebrovascular
accident (CVA) who is receiving enteral tube feedings. Which task
performed by the unlicensed assistive personnel (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
Answer: B
Rationale: Positioning the head of the bed flat when enteral feedings are in progress
puts the client at risk for aspiration. The head of the bed should be maintained at 30–45
degrees during and after enteral feedings to prevent reflux and aspiration pneumonia.
The other actions are appropriate tasks for UAP to perform.
,Question 2: 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
Answer: B
Rationale: Obtaining a fingerstick blood glucose level is a simple treatment and is an
appropriate skill for UAP to perform. Assessment (A), teaching (D), and providing
explanations about the plan of care (C) require the knowledge and judgment of a
licensed nurse and cannot be delegated to UAP.
Question 3: 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
Answer: B
Rationale: Multiple blood transfusions are a risk factor for hyperkalemia. A serum
potassium level higher than 5.0 mEq/L indicates hyperkalemia, which can cause cardiac
arrhythmias. The other values are within normal limits.
Question 4: 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
Answer: 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.
A multidisciplinary consult for rehabilitation should be initiated. Aspirin is
contraindicated with t-PA because it increases the risk for bleeding. t-PA should be
given within 4.5 hours of symptom onset for stroke.
Question 5: A client who is prescribed chlorpromazine HCl
(Thorazine) for schizophrenia develops extrapyramidal side
effects. Which intervention is most important for the nurse to
implement?
A. Administer an anticholinergic medication
B. Provide comfort measures for sore muscles
C. Assess the client for visual and auditory hallucinations
D. Evaluate the client's response to the antipsychotic
Answer: A
Rationale: Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and
masklike face are extrapyramidal side effects associated with chlorpromazine. It is most
important for the nurse to administer an anticholinergic such as Cogentin to reverse
these effects.
, Question 6: 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
Answer: C
Rationale: Another nurse should be asked to take the phone call, which allows the
nurse to stay at the bedside to complete the assessment of the client's chest pain.
Transferring the call during an acute change in condition is inappropriate.
Question 7: When blood or blood products are administered,
which task can be assigned to the licensed practical nurse (LPN)?
A. Initiation of the blood product
B. Obtaining vital signs after infusion has begun
C. Assessment of client's condition prior to blood administration
D. Evaluation of client's response after receiving blood product
Answer: B
Rationale: Blood and blood products must be initiated by the registered nurse (RN);
however, obtaining vital signs may be delegated to the LPN as long as the results are
evaluated by the RN. Assessment and evaluation are within the scope of the RN.
Question 8: The nurse is caring for a client with a cerebrovascular
accident (CVA) who is receiving enteral tube feedings. Which
