EXIT HESI COMPREHENSIVE B EVOLVE
FINAL PAPER QUESTIONS AND
SOLUTIONS
◉ Which vaccination should the nurse administer to a newborn?
A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
D.Meningococcal vaccine
Answer: A
Rationale:
The hepatitis B vaccination should be given to all newborns
before 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 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 (B). (A, C, and D)
are skills that cannot be delegated to UAP.
◉ 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; if bleeding or other signs of
neurologic impairment occur, the infusion should be stopped (B,
C, and E). Aspirin is contraindicated with t-PA because it increases
the risk for bleeding (A). The administration of t-PA within 6
hours of symptoms is concurrent with a diagnosis of a myocardial
infarction and within 4.5 hours of symptoms is concurrent for a
stroke (D).
,◉ When caring for a client in labor, which finding 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
Answer: B
Rationale:
A fetal heart rate (FHR) of 100 beats/min may indicate fetal
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 findings for a woman in labor.
◉ The nurse is caring for a client with heart failure who develops
respiratory distress and coughs up pink frothy sputum. Which
action should the nurse take first?
A.Draw arterial blood gases.
B.Notify the primary health care provider.
C.Position in a high Fowler's position with the legs down.
D.Obtain a chest X-ray.
Answer: C
Rationale:
Positioning the patient in a high Fowler's position with dangling
feet will decrease further venous return to the left ventricle (C).
, The other actions should be performed after the change in
position (A, B, and D).
◉ A client who is prescribed chlorpromazine HCl (Thorazine) for
schizophrenia develops rigidity, a shuffling gait, and tremors.
Which action by the nurse is most important?A.Administer a dose
of benztropine mesylate (Cogentin) PRN.
B.Determine if the client has increased photosensitivity.
C.Provide comfort measures for sore muscles.
D.Assess the client for visual and auditory hallucinations.
Answer: A
Rationale:
Rigidity, shuffling gait, pill-rolling hand movements, tremors,
dyskinesia, and masklike face are extrapyramidal side effects
associated with Thorazine. It is most important for the nurse to
administer an anticholinergic such as Cogentin to reverse these
effects (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 finding would alert the nurse to continue further
assessment of the infant?
A.Two-month-old who is unable to roll from 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
FINAL PAPER QUESTIONS AND
SOLUTIONS
◉ Which vaccination should the nurse administer to a newborn?
A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
D.Meningococcal vaccine
Answer: A
Rationale:
The hepatitis B vaccination should be given to all newborns
before 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 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 (B). (A, C, and D)
are skills that cannot be delegated to UAP.
◉ 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; if bleeding or other signs of
neurologic impairment occur, the infusion should be stopped (B,
C, and E). Aspirin is contraindicated with t-PA because it increases
the risk for bleeding (A). The administration of t-PA within 6
hours of symptoms is concurrent with a diagnosis of a myocardial
infarction and within 4.5 hours of symptoms is concurrent for a
stroke (D).
,◉ When caring for a client in labor, which finding 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
Answer: B
Rationale:
A fetal heart rate (FHR) of 100 beats/min may indicate fetal
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 findings for a woman in labor.
◉ The nurse is caring for a client with heart failure who develops
respiratory distress and coughs up pink frothy sputum. Which
action should the nurse take first?
A.Draw arterial blood gases.
B.Notify the primary health care provider.
C.Position in a high Fowler's position with the legs down.
D.Obtain a chest X-ray.
Answer: C
Rationale:
Positioning the patient in a high Fowler's position with dangling
feet will decrease further venous return to the left ventricle (C).
, The other actions should be performed after the change in
position (A, B, and D).
◉ A client who is prescribed chlorpromazine HCl (Thorazine) for
schizophrenia develops rigidity, a shuffling gait, and tremors.
Which action by the nurse is most important?A.Administer a dose
of benztropine mesylate (Cogentin) PRN.
B.Determine if the client has increased photosensitivity.
C.Provide comfort measures for sore muscles.
D.Assess the client for visual and auditory hallucinations.
Answer: A
Rationale:
Rigidity, shuffling gait, pill-rolling hand movements, tremors,
dyskinesia, and masklike face are extrapyramidal side effects
associated with Thorazine. It is most important for the nurse to
administer an anticholinergic such as Cogentin to reverse these
effects (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 finding would alert the nurse to continue further
assessment of the infant?
A.Two-month-old who is unable to roll from 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
