EXIT HESI Comprehensive B Evolve Practice Questions
1. 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:
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).
2. 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 mEq/L
B.Potassium level, 5.5
,mEq/L
C.Blood urea nitrogen (BUN) level, 18 mg/dL
D.Calcium level, 10 mEq/L:
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).
3. Which vaccination should the nurse administer to a
newborn? A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
D.Meningococcal vaccine:
A Rationale:
The hepatitis B vaccination should be given to all newborns before
hospital dis- charge (A). HPV is not recommended until adolescence
(B). Varicella immunization begins at 12 months (C). Meningococcal
vaccine is administered beginning at 2 years (D).
4. 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.:
B
Rationale:
Obtaining a fingerstick blood glucose level is a simple treatment and is
an appro- priate skill for UAP to perform (B). (A, C, and D) are skills
that cannot be delegated to UAP.
5. The nurse is caring for a client with an ischemic stroke who has a pre-
scription 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.:
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
1. 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:
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).
2. 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 mEq/L
B.Potassium level, 5.5
,mEq/L
C.Blood urea nitrogen (BUN) level, 18 mg/dL
D.Calcium level, 10 mEq/L:
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).
3. Which vaccination should the nurse administer to a
newborn? A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
D.Meningococcal vaccine:
A Rationale:
The hepatitis B vaccination should be given to all newborns before
hospital dis- charge (A). HPV is not recommended until adolescence
(B). Varicella immunization begins at 12 months (C). Meningococcal
vaccine is administered beginning at 2 years (D).
4. 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.:
B
Rationale:
Obtaining a fingerstick blood glucose level is a simple treatment and is
an appro- priate skill for UAP to perform (B). (A, C, and D) are skills
that cannot be delegated to UAP.
5. The nurse is caring for a client with an ischemic stroke who has a pre-
scription 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.:
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
