EXIT HESI Comprehensive B Evolve Practice Questions
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1. The nurse is caring for a client with B
a cerebrovascular accident (CVA) who Rationale:
is receiving enteral tube feedings. Positioning the head of the bed flat when enteral
Which task performed by the UAP re- feedings are in progress puts the client at risk for
quires immediate intervention by the aspiration (B). The others are all acceptable tasks
nurse? performed by the UAP (A, C, and D).
A.Suctions oral secretions from
mouth
B.Positions head of bed flat when
changing sheets
C.Takes temperature using the axil-
lary method
D.Keeps head of bed elevated at 30
degrees
2. When caring for a postsurgical client B
who has undergone multiple blood Rationale:
transfusions, which serum laborato- Multiple blood transfusions are a risk factor for
ry finding is of most concern to the hyperkalemia. A serum potassium level higher than
nurse? 5.0 mEq/L indicates hyperkalemia (B). The others
A.Sodium level, 137 mEq/L are normal findings (A, C, and D).
B.Potassium level, 5.5 mEq/L
C.Blood urea nitrogen (BUN) level, 18
mg/dL
D.Calcium level, 10 mEq/L
3. Which vaccination should the nurse A
administer to a newborn? Rationale:
A.Hepatitis B The hepatitis B vaccination should be given to all
B.Human papilloma virus (HPV) newborns before hospital discharge (A). HPV is
C.Varicella not recommended until adolescence (B). Varicella
D.Meningococcal vaccine immunization begins at 12 months (C). Meningo-
, EXIT HESI Comprehensive B Evolve Practice Questions
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coccal vaccine is administered beginning at 2 years
(D).
4. The nurse is caring for a client on the B
medical unit. Which task can be dele- Rationale:
gated to unlicensed assistive person- Obtaining a fingerstick blood glucose level is a
nel (UAP)? simple treatment and is an appropriate skill for UAP
A.Assess the need to change a central to perform (B). (A, C, and D) are skills that cannot
line dressing. be delegated to UAP.
B.Obtain a fingerstick blood glucose
level.
C.Answer a family member's ques-
tions about the client's plan of care.
D.Teach the client side effects to re-
port related to the current medication
regimen.
5. The nurse is caring for a client with an B,C,E
ischemic stroke who has a prescrip- Rationale:
tion for tissue plasminogen activator Neurologic assessment, including the NIHSS, is
(t-PA) IV. Which action(s) should the indicated for the client receiving t-PA. This includes
nurse expect to implement? (Select all close monitoring for bleeding during and after the
that apply.) infusion; if bleeding or other signs of neurologic
A.Administer aspirin with tissue plas- impairment occur, the infusion should be stopped
minogen activator (t-PA). (B, C, and E). Aspirin is contraindicated with t-PA
B.Complete the National Institute of because it increases the risk for bleeding (A). The
Health Stroke Scale (NIHSS). administration of t-PA within 6 hours of symptoms
C.Assess the client for signs of bleed- is concurrent with a diagnosis of a myocardial in-
ing during and after the infusion. farction and within 4.5 hours of symptoms is con-
D.Start t-PA within 6 hours after the current for a stroke (D).
onset of stroke symptoms.
, EXIT HESI Comprehensive B Evolve Practice Questions
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E.Initiate multidisciplinary consult for
potential rehabilitation.
6. When caring for a client in labor, B
which finding is most important to Rationale:
report to the primary health care A fetal heart rate (FHR) of 100 beats/min may in-
provider? dicate fetal distress (B) because the average FHR
A.Maternal heart rate, 90 beats/min. at term is 140 beats/min and the normal range is
B.Fetal heart rate, 100 beats/min 110 to beats/min 160. The others (A, C, and D) are
C.Maternal blood pressure, 140/86 normal findings for a woman in labor.
mm Hg
D.Maternal temperature, 100.0° F
7. The nurse is caring for a client with C
heart failure who develops respira- Rationale:
tory distress and coughs up pink Positioning the patient in a high Fowler's position
frothy sputum. Which action should with dangling feet will decrease further venous
the nurse take first? return to the left ventricle (C). The other actions
A.Draw arterial blood gases. should be performed after the change in position
B.Notify the primary health care (A, B, and D).
provider.
C.Position in a high Fowler's position
with the legs down.
D.Obtain a chest X-ray.
8. A client who is prescribed chlorpro- A
mazine HCl (Thorazine) for schizo- Rationale:
phrenia develops rigidity, a shuffling Rigidity, shuffling gait, pill-rolling hand move-
gait, and tremors. Which action by the ments, tremors, dyskinesia, and masklike face are
nurse is most important?A.Adminis- extrapyramidal side effects associated with Tho-
ter a dose of benztropine mesylate razine. It is most important for the nurse to ad-
(Cogentin) PRN. minister an anticholinergic such as Cogentin to
, EXIT HESI Comprehensive B Evolve Practice Questions
Study online at https://quizlet.com/_b8799h
B.Determine if the client has in- reverse these effects (A). The others (B, C, D) may
creased photosensitivity. be appropriate interventions but are not as urgent
C.Provide comfort measures for sore as (A).
muscles.
D.Assess the client for visual and audi-
tory hallucinations.
9. A nurse is interviewing a mother dur- B
ing a well-child visit. Which finding Rationale:
would alert the nurse to continue fur- As a developmental milestone, infants should sit
ther assessment of the infant? unsupported by 8 months (B). The milestone of
A.Two-month-old who is unable to roll rolling over is achieved at 5 to 6 months for most
from back to abdomen infants (A). Stranger anxiety is common from 7 to
B.Ten-month-old who cannot sit with- 9 months (C). Speaking a few words is expected at
out support about 12 months (D).
C.Nine-month-old who cries when his
mother leaves the room
D.Eight-month-old who has not yet
begun to speak words
10. Which intervention should be includ- C
ed in the plan of care for a client ad- Rationale:
mitted to the hospital with ulcerative A low-residue diet (C) will help decrease symptoms
colitis? of diarrhea, which are clinical manifestations of
A.Administer stool softeners. ulcerative colitis. (A, B, and D) are contraindicated
B.Place the client on fluid restriction. and could worsen the condition.
C.Provide a low-residue diet.
D.Add a milk product to each meal.
11. The nurse is caring for a client with D
deep vein thrombosis who is on a con- Rationale:
tinuous IV heparin infusion. The acti- An aPTT more than 100 seconds is a critical-
Study online at https://quizlet.com/_b8799h
1. The nurse is caring for a client with B
a cerebrovascular accident (CVA) who Rationale:
is receiving enteral tube feedings. Positioning the head of the bed flat when enteral
Which task performed by the UAP re- feedings are in progress puts the client at risk for
quires immediate intervention by the aspiration (B). The others are all acceptable tasks
nurse? performed by the UAP (A, C, and D).
A.Suctions oral secretions from
mouth
B.Positions head of bed flat when
changing sheets
C.Takes temperature using the axil-
lary method
D.Keeps head of bed elevated at 30
degrees
2. When caring for a postsurgical client B
who has undergone multiple blood Rationale:
transfusions, which serum laborato- Multiple blood transfusions are a risk factor for
ry finding is of most concern to the hyperkalemia. A serum potassium level higher than
nurse? 5.0 mEq/L indicates hyperkalemia (B). The others
A.Sodium level, 137 mEq/L are normal findings (A, C, and D).
B.Potassium level, 5.5 mEq/L
C.Blood urea nitrogen (BUN) level, 18
mg/dL
D.Calcium level, 10 mEq/L
3. Which vaccination should the nurse A
administer to a newborn? Rationale:
A.Hepatitis B The hepatitis B vaccination should be given to all
B.Human papilloma virus (HPV) newborns before hospital discharge (A). HPV is
C.Varicella not recommended until adolescence (B). Varicella
D.Meningococcal vaccine immunization begins at 12 months (C). Meningo-
, EXIT HESI Comprehensive B Evolve Practice Questions
Study online at https://quizlet.com/_b8799h
coccal vaccine is administered beginning at 2 years
(D).
4. The nurse is caring for a client on the B
medical unit. Which task can be dele- Rationale:
gated to unlicensed assistive person- Obtaining a fingerstick blood glucose level is a
nel (UAP)? simple treatment and is an appropriate skill for UAP
A.Assess the need to change a central to perform (B). (A, C, and D) are skills that cannot
line dressing. be delegated to UAP.
B.Obtain a fingerstick blood glucose
level.
C.Answer a family member's ques-
tions about the client's plan of care.
D.Teach the client side effects to re-
port related to the current medication
regimen.
5. The nurse is caring for a client with an B,C,E
ischemic stroke who has a prescrip- Rationale:
tion for tissue plasminogen activator Neurologic assessment, including the NIHSS, is
(t-PA) IV. Which action(s) should the indicated for the client receiving t-PA. This includes
nurse expect to implement? (Select all close monitoring for bleeding during and after the
that apply.) infusion; if bleeding or other signs of neurologic
A.Administer aspirin with tissue plas- impairment occur, the infusion should be stopped
minogen activator (t-PA). (B, C, and E). Aspirin is contraindicated with t-PA
B.Complete the National Institute of because it increases the risk for bleeding (A). The
Health Stroke Scale (NIHSS). administration of t-PA within 6 hours of symptoms
C.Assess the client for signs of bleed- is concurrent with a diagnosis of a myocardial in-
ing during and after the infusion. farction and within 4.5 hours of symptoms is con-
D.Start t-PA within 6 hours after the current for a stroke (D).
onset of stroke symptoms.
, EXIT HESI Comprehensive B Evolve Practice Questions
Study online at https://quizlet.com/_b8799h
E.Initiate multidisciplinary consult for
potential rehabilitation.
6. When caring for a client in labor, B
which finding is most important to Rationale:
report to the primary health care A fetal heart rate (FHR) of 100 beats/min may in-
provider? dicate fetal distress (B) because the average FHR
A.Maternal heart rate, 90 beats/min. at term is 140 beats/min and the normal range is
B.Fetal heart rate, 100 beats/min 110 to beats/min 160. The others (A, C, and D) are
C.Maternal blood pressure, 140/86 normal findings for a woman in labor.
mm Hg
D.Maternal temperature, 100.0° F
7. The nurse is caring for a client with C
heart failure who develops respira- Rationale:
tory distress and coughs up pink Positioning the patient in a high Fowler's position
frothy sputum. Which action should with dangling feet will decrease further venous
the nurse take first? return to the left ventricle (C). The other actions
A.Draw arterial blood gases. should be performed after the change in position
B.Notify the primary health care (A, B, and D).
provider.
C.Position in a high Fowler's position
with the legs down.
D.Obtain a chest X-ray.
8. A client who is prescribed chlorpro- A
mazine HCl (Thorazine) for schizo- Rationale:
phrenia develops rigidity, a shuffling Rigidity, shuffling gait, pill-rolling hand move-
gait, and tremors. Which action by the ments, tremors, dyskinesia, and masklike face are
nurse is most important?A.Adminis- extrapyramidal side effects associated with Tho-
ter a dose of benztropine mesylate razine. It is most important for the nurse to ad-
(Cogentin) PRN. minister an anticholinergic such as Cogentin to
, EXIT HESI Comprehensive B Evolve Practice Questions
Study online at https://quizlet.com/_b8799h
B.Determine if the client has in- reverse these effects (A). The others (B, C, D) may
creased photosensitivity. be appropriate interventions but are not as urgent
C.Provide comfort measures for sore as (A).
muscles.
D.Assess the client for visual and audi-
tory hallucinations.
9. A nurse is interviewing a mother dur- B
ing a well-child visit. Which finding Rationale:
would alert the nurse to continue fur- As a developmental milestone, infants should sit
ther assessment of the infant? unsupported by 8 months (B). The milestone of
A.Two-month-old who is unable to roll rolling over is achieved at 5 to 6 months for most
from back to abdomen infants (A). Stranger anxiety is common from 7 to
B.Ten-month-old who cannot sit with- 9 months (C). Speaking a few words is expected at
out support about 12 months (D).
C.Nine-month-old who cries when his
mother leaves the room
D.Eight-month-old who has not yet
begun to speak words
10. Which intervention should be includ- C
ed in the plan of care for a client ad- Rationale:
mitted to the hospital with ulcerative A low-residue diet (C) will help decrease symptoms
colitis? of diarrhea, which are clinical manifestations of
A.Administer stool softeners. ulcerative colitis. (A, B, and D) are contraindicated
B.Place the client on fluid restriction. and could worsen the condition.
C.Provide a low-residue diet.
D.Add a milk product to each meal.
11. The nurse is caring for a client with D
deep vein thrombosis who is on a con- Rationale:
tinuous IV heparin infusion. The acti- An aPTT more than 100 seconds is a critical-
