HESI EXIT COMPREHENSIVE B EVOLVE
PRACTICE QUESTIONS WITH CORRECT
SOLUTION
The Nurse Is Caring For A Client With A Cerebrovascular Accident (Cva) Who
Is Receiving Enteral Tube Feedings. Which Task Performed By The 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 (B). The Others Are All Acceptable
Tasks Performed By The Uap (A, C, And D).
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 Meg/L
B. Potassium Level, 5.5 Meg/L
C. Blood Urea Nitrogen (Bun) Level, 18 Mg/Dl
D. Calcium Level, 10 Meg/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 (B). The
Others Are Normal Findings (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 -
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?
PRACTICE QUESTIONS WITH CORRECT
SOLUTION
The Nurse Is Caring For A Client With A Cerebrovascular Accident (Cva) Who
Is Receiving Enteral Tube Feedings. Which Task Performed By The 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 (B). The Others Are All Acceptable
Tasks Performed By The Uap (A, C, And D).
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 Meg/L
B. Potassium Level, 5.5 Meg/L
C. Blood Urea Nitrogen (Bun) Level, 18 Mg/Dl
D. Calcium Level, 10 Meg/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 (B). The
Others Are Normal Findings (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 -
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?
