EXIT HESI – Comprehensive PN Exam B | Evolve Practice Scenarios | U.S. Nursing Schools | 2024 | NCLEX-Style Questions with Rationales

EXIT HESI Comprehensive B Evolve Practice Questions

Cerebrovascular Accident (CVA) and Enteral Feedings

Clinical Scenario: A nurse is caring for a client with a cerebrovascular accident (CVA) who is
receiving enteral tube feedings.

Question: Which task performed by the Unlicensed Assistive Personnel (UAP) requires immediate
intervention by the nurse?

Options: 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

Rationale:

 Correct Answer: B
 Positioning the head of the bed flat when enteral feedings are in progress puts the client at
significant risk for aspiration.
 Options A, C, and D are all acceptable tasks for a UAP to perform.

Postoperative Blood Transfusions and Laboratory Findings

Clinical Scenario: A nurse is caring for a postsurgical client who has undergone multiple blood
transfusions.

Question: Which serum laboratory finding is of most concern to the nurse?

Options: 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

Rationale:

 Correct Answer: B



,  Multiple blood transfusions are a known risk factor for hyperkalemia.
 A serum potassium level higher than 5.0 mEq/L indicates hyperkalemia.
 Options A, C, and D represent normal findings.

Newborn Vaccinations

Question: Which vaccination should the nurse administer to a newborn?

Options: A. Hepatitis B B. Human papilloma virus (HPV) C. Varicella D. Meningococcal vaccine

Rationale:

 Correct Answer: A
 The Hepatitis B vaccination should be given to all newborns before hospital discharge.
 HPV vaccination is not recommended until adolescence.
 Varicella immunization typically begins at 12 months of age.
 Meningococcal vaccine is usually administered beginning at 2 years of age.

Delegation of Tasks to Unlicensed Assistive Personnel (UAP)

Clinical Scenario: The nurse is caring for a client on the medical unit.

Question: Which task can be delegated to unlicensed assistive personnel (UAP)?

Options: 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.

Rationale:

 Correct Answer: B
 Obtaining a fingerstick blood glucose level is considered a simple treatment and is an
appropriate skill for UAP to perform.



,  Options A, C, and D involve assessment, education, and care planning, which are skills that
cannot be delegated to UAP.

Ischemic Stroke and Tissue Plasminogen Activator (t-PA)

Clinical Scenario: The nurse is caring for a client with an ischemic stroke who has a prescription for
tissue plasminogen activator (t-PA) IV.

Question: Which action(s) should the nurse expect to implement? (Select all that apply.)

Options: 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.

Rationale:

 Correct Answers: B, C, and E
 Neurologic assessment, including the NIHSS, is indicated for clients receiving t-PA.
 Close monitoring for bleeding during and after the infusion is crucial; if bleeding or other signs
of neurologic impairment occur, the infusion should be stopped.
 Initiating a multidisciplinary consult for potential rehabilitation is a key component of post-
stroke care.
 Aspirin is contraindicated with t-PA because it increases the risk for bleeding.
 The administration of t-PA should ideally occur within 4.5 hours of stroke symptom onset.

Labor and Fetal Heart Rate

Clinical Scenario: When caring for a client in labor.

Question: Which finding is most important to report to the primary health care provider?





, Options: 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

Rationale:

 Correct Answer: B
 A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress.
 The average FHR at term is around 140 beats/min, with a normal range of 110 to 160 beats/min
 Options A, C, and D are generally within normal limits for a woman in labor.

Heart Failure and Respiratory Distress

Clinical Scenario: The nurse is caring for a client with heart failure who develops respiratory distress
and coughs up pink frothy sputum.

Question: Which action should the nurse take first?

Options: 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.

Rationale:

 Correct Answer: C
 Positioning the patient in a high Fowler's position with dangling feet will help decrease further
venous return to the left ventricle, alleviating respiratory distress.
 The other actions (A, B, and D) should be performed after the change in position.

Schizophrenia and Extrapyramidal Side Effects

Clinical Scenario: A client who is prescribed chlorpromazine HCl (Thorazine) for schizophrenia
develops rigidity, a shuffling gait, and tremors.

Question: Which action by the nurse is most important?