EXIT HESI Comprehensive B Evolve
Practice (Latest Update )
Questions with 100% Correct answers and
Rationales [Grade A] - Nightingale
Which intervention should be included in the plan of care for a client admitted to the
hospital with ulcerative colitis?
A.Administer stool softeners.
B.Place the client on fluid restriction.
C.Provide a low-residue diet.
D.Add a milk product to each meal. - correct answer C
Rationale:
A low-residue diet (C) will help decrease symptoms of diarrhea, which are clinical
manifestations of ulcerative colitis. (A, B, and D) are contraindicated and could
worsen the condition.
The nurse is caring for a client with deep vein thrombosis who is on a continuous IV
heparin infusion. The activated partial prothrombin time (aPTT) is 120 seconds. Which
action should the nurse take?
, EXIT HESI Comprehensive B Evolve
Practice (Latest Update )
Questions with 100% Correct answers and
Rationales [Grade A] - Nightingale
A.Increase the rate of the heparin infusion using a nomogram.
B.Decrease the heparin infusion rate and give vitamin K IM.
C.Continue the heparin infusion at the current prescribed rate.
D.Stop the heparin drip and prepare to administer protamine sulfate. - correct answer
D
Rationale:
An aPTT more than 100 seconds is a critically high value; therefore, the heparin should
be stopped. The antidote for heparin is protamine sulfate (D). Increasing the rate
would increase the risk for hemorrhage (A). The infusion should be stopped, and
vitamin K is the antidote for warfarin (Coumadin) (B). Keeping the infusion at the
current rate would increase the risk for hemorrhage (C).
While assessing a client with recurring chest pain, the unit secretary notifies the nurse
that the client's health care provider is on the telephone. What action should the
nurse instruct the unit secretary to implement?
, EXIT HESI Comprehensive B Evolve
Practice (Latest Update )
Questions with 100% Correct answers and
Rationales [Grade A] - Nightingale
A.Transfer the call into the room of the client.
B.Instruct the secretary to explain reason for the call.
C.Ask another nurse to take the phone call.
D.Ask the health care provider to see the client on the unit. - correct answer C
Rationale:
Another nurse should be asked to take the phone call (C), which allows the nurse to
stay at the bedside to complete the assessment of the client's chest pain. (A and B)
should not be done during an acute change in the client's condition. Requesting the
health care provider (D) to come to the unit is premature until the nurse completes
assessment of the client's status.
Which instruction(s) should the nurse include in the discharge teaching plan of a male
client who has had a myocardial infarction and who has a new prescription for
nitroglycerin (NTG)? (Select all that apply.)
A.Keep the medication in your pocket so that it can be accessed quickly.
, EXIT HESI Comprehensive B Evolve
Practice (Latest Update )
Questions with 100% Correct answers and
Rationales [Grade A] - Nightingale
B.Call 911 if chest pain is not relieved after one nitroglycerin.
C.Store the medication in its original container and protect it from light.
D.Activate the emergency medical system after three doses of medication.
E.Do not use within 1 hour of taking sildenafil citrate (Viagra). - correct answer B,C
Rationale:
Emergency action should be taken if chest pain is not relieved after one nitroglycerin
tablet (B). The medication should be kept in the original container to protect from
light (C). Keeping the medication in the shirt pocket provides an environment that is
too warm (A). The newest guidelines recommend calling 911 after one nitroglycerin
tablet if chest pain is not relieved (D). Nitroglycerin and other nitrates should never
be taken with Viagra (E).
The nurse prepares to administer 3 units of regular insulin and 20 units of NPH insulin
subcutaneously to a client with an elevated blood glucose level. Which procedure is
correct?
Practice (Latest Update )
Questions with 100% Correct answers and
Rationales [Grade A] - Nightingale
Which intervention should be included in the plan of care for a client admitted to the
hospital with ulcerative colitis?
A.Administer stool softeners.
B.Place the client on fluid restriction.
C.Provide a low-residue diet.
D.Add a milk product to each meal. - correct answer C
Rationale:
A low-residue diet (C) will help decrease symptoms of diarrhea, which are clinical
manifestations of ulcerative colitis. (A, B, and D) are contraindicated and could
worsen the condition.
The nurse is caring for a client with deep vein thrombosis who is on a continuous IV
heparin infusion. The activated partial prothrombin time (aPTT) is 120 seconds. Which
action should the nurse take?
, EXIT HESI Comprehensive B Evolve
Practice (Latest Update )
Questions with 100% Correct answers and
Rationales [Grade A] - Nightingale
A.Increase the rate of the heparin infusion using a nomogram.
B.Decrease the heparin infusion rate and give vitamin K IM.
C.Continue the heparin infusion at the current prescribed rate.
D.Stop the heparin drip and prepare to administer protamine sulfate. - correct answer
D
Rationale:
An aPTT more than 100 seconds is a critically high value; therefore, the heparin should
be stopped. The antidote for heparin is protamine sulfate (D). Increasing the rate
would increase the risk for hemorrhage (A). The infusion should be stopped, and
vitamin K is the antidote for warfarin (Coumadin) (B). Keeping the infusion at the
current rate would increase the risk for hemorrhage (C).
While assessing a client with recurring chest pain, the unit secretary notifies the nurse
that the client's health care provider is on the telephone. What action should the
nurse instruct the unit secretary to implement?
, EXIT HESI Comprehensive B Evolve
Practice (Latest Update )
Questions with 100% Correct answers and
Rationales [Grade A] - Nightingale
A.Transfer the call into the room of the client.
B.Instruct the secretary to explain reason for the call.
C.Ask another nurse to take the phone call.
D.Ask the health care provider to see the client on the unit. - correct answer C
Rationale:
Another nurse should be asked to take the phone call (C), which allows the nurse to
stay at the bedside to complete the assessment of the client's chest pain. (A and B)
should not be done during an acute change in the client's condition. Requesting the
health care provider (D) to come to the unit is premature until the nurse completes
assessment of the client's status.
Which instruction(s) should the nurse include in the discharge teaching plan of a male
client who has had a myocardial infarction and who has a new prescription for
nitroglycerin (NTG)? (Select all that apply.)
A.Keep the medication in your pocket so that it can be accessed quickly.
, EXIT HESI Comprehensive B Evolve
Practice (Latest Update )
Questions with 100% Correct answers and
Rationales [Grade A] - Nightingale
B.Call 911 if chest pain is not relieved after one nitroglycerin.
C.Store the medication in its original container and protect it from light.
D.Activate the emergency medical system after three doses of medication.
E.Do not use within 1 hour of taking sildenafil citrate (Viagra). - correct answer B,C
Rationale:
Emergency action should be taken if chest pain is not relieved after one nitroglycerin
tablet (B). The medication should be kept in the original container to protect from
light (C). Keeping the medication in the shirt pocket provides an environment that is
too warm (A). The newest guidelines recommend calling 911 after one nitroglycerin
tablet if chest pain is not relieved (D). Nitroglycerin and other nitrates should never
be taken with Viagra (E).
The nurse prepares to administer 3 units of regular insulin and 20 units of NPH insulin
subcutaneously to a client with an elevated blood glucose level. Which procedure is
correct?
