EXIT HESI COMPREHENSIVE B EVOLVE
PRACTICE QUESTIONS WITH [A
GRADED] ANSWERS
The ynurse yis ycaring yfor ya yclient ywith ya ycerebrovascular yaccident y(CVA) ywho yis
yreceiving yenteral ytube yfeedings. yWhich ytask yperformed yby ythe yUAP yrequires
yimmediate yintervention yby ythe ynurse?
A.Suctions yoral ysecretions yfrom ymouth
B.Positions yhead yof ybed yflat ywhen ychanging ysheets
C.Takes ytemperature yusing ythe yaxillary ymethod
D.Keeps yhead yof ybed yelevated yat y30 ydegrees y- yANS--B
Rationale:
Positioning ythe yhead yof ythe ybed yflat ywhen yenteral yfeedings yare yin yprogress yputs
ythe yclient yat yrisk yfor yaspiration y(B). yThe yothers yare yall yacceptable ytasks
yperformed yby ythe yUAP y(A, yC, yand yD).
When ycaring yfor ya ypostsurgical yclient ywho yhas yundergone ymultiple yblood
ytransfusions, ywhich yserum ylaboratory yfinding yis yof ymost yconcern yto ythe ynurse?
A.Sodium ylevel, y137 ymEq/L
B.Potassium ylevel, y5.5 ymEq/L
C.Blood yurea ynitrogen y(BUN) ylevel, y18 ymg/dL
D.Calcium ylevel, y10 ymEq/L y- yANS--B
Rationale:
Multiple yblood ytransfusions yare ya yrisk yfactor yfor yhyperkalemia. yA yserum ypotassium
ylevel yhigher ythan y5.0 ymEq/L yindicates yhyperkalemia y(B). yThe yothers yare ynormal
yfindings y(A, yC, yand yD).
Which yvaccination yshould ythe ynurse yadminister yto ya ynewborn?
A.Hepatitis yB
B.Human ypapilloma yvirus y(HPV)
C.Varicella
D.Meningococcal yvaccine y- yANS--A
Rationale:
The yhepatitis yB yvaccination yshould ybe ygiven yto yall ynewborns ybefore yhospital
ydischarge y(A). yHPV yis ynot yrecommended yuntil yadolescence y(B). yVaricella
yimmunization ybegins yat y12 ymonths y(C). yMeningococcal yvaccine yis yadministered
ybeginning yat y2 yyears y(D).
The ynurse yis ycaring yfor ya yclient yon ythe ymedical yunit. yWhich ytask ycan ybe
ydelegated yto yunlicensed yassistive ypersonnel y(UAP)?
,A.Assess ythe yneed yto ychange ya ycentral yline ydressing.
B.Obtain ya yfingerstick yblood yglucose ylevel.
C.Answer ya yfamily ymember's yquestions yabout ythe yclient's yplan yof ycare.
D.Teach ythe yclient yside yeffects yto yreport yrelated yto ythe ycurrent ymedication
yregimen. y- yANS--B
Rationale:
Obtaining ya yfingerstick yblood yglucose ylevel yis ya ysimple ytreatment yand yis yan
yappropriate yskill yfor yUAP yto yperform y(B). y(A, yC, yand yD) yare yskills ythat ycannot ybe
ydelegated yto yUAP.
The ynurse yis ycaring yfor ya yclient ywith yan yischemic ystroke ywho yhas ya yprescription
yfor ytissue yplasminogen yactivator y(t-PA) yIV. yWhich yaction(s) yshould ythe ynurse
yexpect yto yimplement? y(Select yall ythat yapply.)
A.Administer yaspirin ywith ytissue yplasminogen yactivator y(t-PA).
B.Complete ythe yNational yInstitute yof yHealth yStroke yScale y(NIHSS).
C.Assess ythe yclient yfor ysigns yof ybleeding yduring yand yafter ythe yinfusion.
D.Start yt-PA ywithin y6 yhours yafter ythe yonset yof ystroke ysymptoms.
E.Initiate ymultidisciplinary yconsult yfor ypotential yrehabilitation. y- yANS--B,C,E
Rationale:
Neurologic yassessment, yincluding ythe yNIHSS, yis yindicated yfor ythe yclient yreceiving
yt-PA. yThis yincludes yclose ymonitoring yfor ybleeding yduring yand yafter ythe yinfusion; yif
ybleeding yor yother ysigns yof yneurologic yimpairment yoccur, ythe yinfusion yshould ybe
ystopped y(B, yC, yand yE). yAspirin yis ycontraindicated ywith yt-PA ybecause yit yincreases
ythe yrisk yfor ybleeding y(A). yThe yadministration yof yt-PA ywithin y6 yhours yof ysymptoms
yis yconcurrent ywith ya ydiagnosis yof ya ymyocardial yinfarction yand ywithin y4.5 yhours yof
ysymptoms yis yconcurrent yfor ya ystroke y(D).
When ycaring yfor ya yclient yin ylabor, ywhich yfinding yis ymost yimportant yto yreport yto ythe
yprimary yhealth ycare yprovider?
A.Maternal yheart yrate, y90 ybeats/min.
B.Fetal yheart yrate, y100 ybeats/min
C.Maternal yblood ypressure, y140/86 ymm yHg
D.Maternal ytemperature, y100.0° yF y- yANS--B
Rationale:
A yfetal yheart yrate y(FHR) yof y100 ybeats/min ymay yindicate yfetal ydistress y(B) ybecause
ythe yaverage yFHR yat yterm yis y140 ybeats/min yand ythe ynormal yrange yis y110 yto
ybeats/min y160. yThe yothers y(A, yC, yand yD) yare ynormal yfindings yfor ya ywoman yin
ylabor.
The ynurse yis ycaring yfor ya yclient ywith yheart yfailure ywho ydevelops yrespiratory
ydistress yand ycoughs yup ypink yfrothy ysputum. yWhich yaction yshould ythe ynurse ytake
yfirst?
A.Draw yarterial yblood ygases.
B.Notify ythe yprimary yhealth ycare yprovider.
C.Position yin ya yhigh yFowler's yposition ywith ythe ylegs ydown.
D.Obtain ya ychest yX-ray. y- yANS--C
, Rationale:
Positioning ythe ypatient yin ya yhigh yFowler's yposition ywith ydangling yfeet ywill ydecrease
yfurther yvenous yreturn yto ythe yleft yventricle y(C). yThe yother yactions yshould ybe
yperformed yafter ythe ychange yin yposition y(A, yB, yand yD).
A yclient ywho yis yprescribed ychlorpromazine yHCl y(Thorazine) yfor yschizophrenia
ydevelops yrigidity, ya yshuffling ygait, yand ytremors. yWhich yaction yby ythe ynurse yis
ymost yimportant?A.Administer ya ydose yof ybenztropine ymesylate y(Cogentin) yPRN.
B.Determine yif ythe yclient yhas yincreased yphotosensitivity.
C.Provide ycomfort ymeasures yfor ysore ymuscles.
D.Assess ythe yclient yfor yvisual yand yauditory yhallucinations. y- yANS--A
Rationale:
Rigidity, yshuffling ygait, ypill-rolling yhand ymovements, ytremors, ydyskinesia, yand
ymasklike yface yare yextrapyramidal yside yeffects yassociated ywith yThorazine. yIt yis
ymost yimportant yfor ythe ynurse yto yadminister yan yanticholinergic ysuch yas yCogentin yto
yreverse ythese yeffects y(A). yThe yothers y(B, yC, yD) ymay ybe yappropriate yinterventions
ybut yare ynot yas yurgent yas y(A).
A ynurse yis yinterviewing ya ymother yduring ya ywell-child yvisit. yWhich yfinding ywould
yalert ythe ynurse yto ycontinue yfurther yassessment yof ythe yinfant?
A.Two-month-old ywho yis yunable yto yroll yfrom yback yto yabdomen
B.Ten-month-old ywho ycannot ysit ywithout ysupport
C.Nine-month-old ywho ycries ywhen yhis ymother yleaves ythe yroom
D.Eight-month-old ywho yhas ynot yyet ybegun yto yspeak ywords y- yANS--B
Rationale:
As ya ydevelopmental ymilestone, yinfants yshould ysit yunsupported yby y8 ymonths y(B).
yThe ymilestone yof yrolling yover yis yachieved yat y5 yto y6 ymonths yfor ymost yinfants y(A).
yStranger yanxiety yis ycommon yfrom y7 yto y9 ymonths y(C). ySpeaking ya yfew ywords yis
yexpected yat yabout y12 ymonths y(D).
Which yintervention yshould ybe yincluded yin ythe yplan yof ycare yfor ya yclient yadmitted yto
ythe yhospital ywith yulcerative ycolitis?
A.Administer ystool ysofteners.
B.Place ythe yclient yon yfluid yrestriction.
C.Provide ya ylow-residue ydiet.
D.Add ya ymilk yproduct yto yeach ymeal. y- yANS--C
Rationale:
A ylow-residue ydiet y(C) ywill yhelp ydecrease ysymptoms yof ydiarrhea, ywhich yare yclinical
ymanifestations yof yulcerative ycolitis. y(A, yB, yand yD) yare ycontraindicated yand ycould
yworsen ythe ycondition.
The ynurse yis ycaring yfor ya yclient ywith ydeep yvein ythrombosis ywho yis yon ya
ycontinuous yIV yheparin yinfusion. yThe yactivated ypartial yprothrombin ytime y(aPTT) yis
y120 yseconds. yWhich yaction yshould ythe ynurse ytake?
A.Increase ythe yrate yof ythe yheparin yinfusion yusing ya ynomogram.
B.Decrease ythe yheparin yinfusion yrate yand ygive yvitamin yK yIM.
PRACTICE QUESTIONS WITH [A
GRADED] ANSWERS
The ynurse yis ycaring yfor ya yclient ywith ya ycerebrovascular yaccident y(CVA) ywho yis
yreceiving yenteral ytube yfeedings. yWhich ytask yperformed yby ythe yUAP yrequires
yimmediate yintervention yby ythe ynurse?
A.Suctions yoral ysecretions yfrom ymouth
B.Positions yhead yof ybed yflat ywhen ychanging ysheets
C.Takes ytemperature yusing ythe yaxillary ymethod
D.Keeps yhead yof ybed yelevated yat y30 ydegrees y- yANS--B
Rationale:
Positioning ythe yhead yof ythe ybed yflat ywhen yenteral yfeedings yare yin yprogress yputs
ythe yclient yat yrisk yfor yaspiration y(B). yThe yothers yare yall yacceptable ytasks
yperformed yby ythe yUAP y(A, yC, yand yD).
When ycaring yfor ya ypostsurgical yclient ywho yhas yundergone ymultiple yblood
ytransfusions, ywhich yserum ylaboratory yfinding yis yof ymost yconcern yto ythe ynurse?
A.Sodium ylevel, y137 ymEq/L
B.Potassium ylevel, y5.5 ymEq/L
C.Blood yurea ynitrogen y(BUN) ylevel, y18 ymg/dL
D.Calcium ylevel, y10 ymEq/L y- yANS--B
Rationale:
Multiple yblood ytransfusions yare ya yrisk yfactor yfor yhyperkalemia. yA yserum ypotassium
ylevel yhigher ythan y5.0 ymEq/L yindicates yhyperkalemia y(B). yThe yothers yare ynormal
yfindings y(A, yC, yand yD).
Which yvaccination yshould ythe ynurse yadminister yto ya ynewborn?
A.Hepatitis yB
B.Human ypapilloma yvirus y(HPV)
C.Varicella
D.Meningococcal yvaccine y- yANS--A
Rationale:
The yhepatitis yB yvaccination yshould ybe ygiven yto yall ynewborns ybefore yhospital
ydischarge y(A). yHPV yis ynot yrecommended yuntil yadolescence y(B). yVaricella
yimmunization ybegins yat y12 ymonths y(C). yMeningococcal yvaccine yis yadministered
ybeginning yat y2 yyears y(D).
The ynurse yis ycaring yfor ya yclient yon ythe ymedical yunit. yWhich ytask ycan ybe
ydelegated yto yunlicensed yassistive ypersonnel y(UAP)?
,A.Assess ythe yneed yto ychange ya ycentral yline ydressing.
B.Obtain ya yfingerstick yblood yglucose ylevel.
C.Answer ya yfamily ymember's yquestions yabout ythe yclient's yplan yof ycare.
D.Teach ythe yclient yside yeffects yto yreport yrelated yto ythe ycurrent ymedication
yregimen. y- yANS--B
Rationale:
Obtaining ya yfingerstick yblood yglucose ylevel yis ya ysimple ytreatment yand yis yan
yappropriate yskill yfor yUAP yto yperform y(B). y(A, yC, yand yD) yare yskills ythat ycannot ybe
ydelegated yto yUAP.
The ynurse yis ycaring yfor ya yclient ywith yan yischemic ystroke ywho yhas ya yprescription
yfor ytissue yplasminogen yactivator y(t-PA) yIV. yWhich yaction(s) yshould ythe ynurse
yexpect yto yimplement? y(Select yall ythat yapply.)
A.Administer yaspirin ywith ytissue yplasminogen yactivator y(t-PA).
B.Complete ythe yNational yInstitute yof yHealth yStroke yScale y(NIHSS).
C.Assess ythe yclient yfor ysigns yof ybleeding yduring yand yafter ythe yinfusion.
D.Start yt-PA ywithin y6 yhours yafter ythe yonset yof ystroke ysymptoms.
E.Initiate ymultidisciplinary yconsult yfor ypotential yrehabilitation. y- yANS--B,C,E
Rationale:
Neurologic yassessment, yincluding ythe yNIHSS, yis yindicated yfor ythe yclient yreceiving
yt-PA. yThis yincludes yclose ymonitoring yfor ybleeding yduring yand yafter ythe yinfusion; yif
ybleeding yor yother ysigns yof yneurologic yimpairment yoccur, ythe yinfusion yshould ybe
ystopped y(B, yC, yand yE). yAspirin yis ycontraindicated ywith yt-PA ybecause yit yincreases
ythe yrisk yfor ybleeding y(A). yThe yadministration yof yt-PA ywithin y6 yhours yof ysymptoms
yis yconcurrent ywith ya ydiagnosis yof ya ymyocardial yinfarction yand ywithin y4.5 yhours yof
ysymptoms yis yconcurrent yfor ya ystroke y(D).
When ycaring yfor ya yclient yin ylabor, ywhich yfinding yis ymost yimportant yto yreport yto ythe
yprimary yhealth ycare yprovider?
A.Maternal yheart yrate, y90 ybeats/min.
B.Fetal yheart yrate, y100 ybeats/min
C.Maternal yblood ypressure, y140/86 ymm yHg
D.Maternal ytemperature, y100.0° yF y- yANS--B
Rationale:
A yfetal yheart yrate y(FHR) yof y100 ybeats/min ymay yindicate yfetal ydistress y(B) ybecause
ythe yaverage yFHR yat yterm yis y140 ybeats/min yand ythe ynormal yrange yis y110 yto
ybeats/min y160. yThe yothers y(A, yC, yand yD) yare ynormal yfindings yfor ya ywoman yin
ylabor.
The ynurse yis ycaring yfor ya yclient ywith yheart yfailure ywho ydevelops yrespiratory
ydistress yand ycoughs yup ypink yfrothy ysputum. yWhich yaction yshould ythe ynurse ytake
yfirst?
A.Draw yarterial yblood ygases.
B.Notify ythe yprimary yhealth ycare yprovider.
C.Position yin ya yhigh yFowler's yposition ywith ythe ylegs ydown.
D.Obtain ya ychest yX-ray. y- yANS--C
, Rationale:
Positioning ythe ypatient yin ya yhigh yFowler's yposition ywith ydangling yfeet ywill ydecrease
yfurther yvenous yreturn yto ythe yleft yventricle y(C). yThe yother yactions yshould ybe
yperformed yafter ythe ychange yin yposition y(A, yB, yand yD).
A yclient ywho yis yprescribed ychlorpromazine yHCl y(Thorazine) yfor yschizophrenia
ydevelops yrigidity, ya yshuffling ygait, yand ytremors. yWhich yaction yby ythe ynurse yis
ymost yimportant?A.Administer ya ydose yof ybenztropine ymesylate y(Cogentin) yPRN.
B.Determine yif ythe yclient yhas yincreased yphotosensitivity.
C.Provide ycomfort ymeasures yfor ysore ymuscles.
D.Assess ythe yclient yfor yvisual yand yauditory yhallucinations. y- yANS--A
Rationale:
Rigidity, yshuffling ygait, ypill-rolling yhand ymovements, ytremors, ydyskinesia, yand
ymasklike yface yare yextrapyramidal yside yeffects yassociated ywith yThorazine. yIt yis
ymost yimportant yfor ythe ynurse yto yadminister yan yanticholinergic ysuch yas yCogentin yto
yreverse ythese yeffects y(A). yThe yothers y(B, yC, yD) ymay ybe yappropriate yinterventions
ybut yare ynot yas yurgent yas y(A).
A ynurse yis yinterviewing ya ymother yduring ya ywell-child yvisit. yWhich yfinding ywould
yalert ythe ynurse yto ycontinue yfurther yassessment yof ythe yinfant?
A.Two-month-old ywho yis yunable yto yroll yfrom yback yto yabdomen
B.Ten-month-old ywho ycannot ysit ywithout ysupport
C.Nine-month-old ywho ycries ywhen yhis ymother yleaves ythe yroom
D.Eight-month-old ywho yhas ynot yyet ybegun yto yspeak ywords y- yANS--B
Rationale:
As ya ydevelopmental ymilestone, yinfants yshould ysit yunsupported yby y8 ymonths y(B).
yThe ymilestone yof yrolling yover yis yachieved yat y5 yto y6 ymonths yfor ymost yinfants y(A).
yStranger yanxiety yis ycommon yfrom y7 yto y9 ymonths y(C). ySpeaking ya yfew ywords yis
yexpected yat yabout y12 ymonths y(D).
Which yintervention yshould ybe yincluded yin ythe yplan yof ycare yfor ya yclient yadmitted yto
ythe yhospital ywith yulcerative ycolitis?
A.Administer ystool ysofteners.
B.Place ythe yclient yon yfluid yrestriction.
C.Provide ya ylow-residue ydiet.
D.Add ya ymilk yproduct yto yeach ymeal. y- yANS--C
Rationale:
A ylow-residue ydiet y(C) ywill yhelp ydecrease ysymptoms yof ydiarrhea, ywhich yare yclinical
ymanifestations yof yulcerative ycolitis. y(A, yB, yand yD) yare ycontraindicated yand ycould
yworsen ythe ycondition.
The ynurse yis ycaring yfor ya yclient ywith ydeep yvein ythrombosis ywho yis yon ya
ycontinuous yIV yheparin yinfusion. yThe yactivated ypartial yprothrombin ytime y(aPTT) yis
y120 yseconds. yWhich yaction yshould ythe ynurse ytake?
A.Increase ythe yrate yof ythe yheparin yinfusion yusing ya ynomogram.
B.Decrease ythe yheparin yinfusion yrate yand ygive yvitamin yK yIM.
