HESI Exit Comprehensive B Evolve | Actual
Questions and Answers Latest Updated
2025/2026 (Graded A+)
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..i
mmediate..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..-....
Correct..Answer-B
Rationale:
Positioning..the..head..of..the..bed..flat..when..enteral..feedings..are..in..progress..put
s..the..client..at..risk..for..aspiration..(B)...The..others..are..all..acceptable..tasks..perfo
rmed..by..the..UAP..(A,..C,..and..D).
When..caring..for..a..postsurgical..client..who..has..undergone..multiple..blood..trans
fusions,..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..-....
Correct..Answer-B
Rationale:
Multiple..blood..transfusions..are..a..risk..factor..for..hyperkalemia...A..serum..potass
ium..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..-....
Correct..Answer-A
Rationale:
The..hepatitis..B..vaccination..should..be..given..to..all..newborns..before..hospital..d
ischarge..(A)...HPV..is..not..recommended..until..adolescence..(B)...Varicella..immu
nization..begins..at..12..months..(C)...Meningococcal..vaccine..is..administered..beg
inning..at..2..years..(D).
The..nurse..is..caring..for..a..client..on..the..medical..unit...Which..task..can..be..delega
ted..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..regi
men...-....
Correct..Answer-B
,Rationale:
Obtaining..a..fingerstick..blood..glucose..level..is..a..simple..treatment..and..is..an..ap
propriate..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..prescriptio
n..for..tissue..plasminogen..activator..(t-
PA)..IV...Which..action(s)..should..the..nurse..expect..to..implement?..(Select..all..tha
t..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...-....
Correct..Answer-B,C,E
Rationale:
Neurologic..assessment,..including..the..NIHSS,..is..indicated..for..the..client..recei
ving..t-
PA...This..includes..close..monitoring..for..bleeding..during..and..after..the..infusion;
..if..bleeding..or..other..signs..of..neurologic..impairment..occur,..the..infusion..shoul
d..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..myocardia
l..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..-....
Correct..Answer-B
Rationale:
A..fetal..heart..rate..(FHR)..of..100..beats/min..may..indicate..fetal..distress..(B)..beca
use..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..l
abor.
The..nurse..is..caring..for..a..client..with..heart..failure..who..develops..respiratory..dis
tress..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...-....
Correct..Answer-C
Rationale:
Positioning..the..patient..in..a..high..Fowler's..position..with..dangling..feet..will..dec
rease..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)..PR
N.
B.Determine..if..the..client..has..increased..photosensitivity.
C.Provide..comfort..measures..for..sore..muscles.
Questions and Answers Latest Updated
2025/2026 (Graded A+)
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..i
mmediate..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..-....
Correct..Answer-B
Rationale:
Positioning..the..head..of..the..bed..flat..when..enteral..feedings..are..in..progress..put
s..the..client..at..risk..for..aspiration..(B)...The..others..are..all..acceptable..tasks..perfo
rmed..by..the..UAP..(A,..C,..and..D).
When..caring..for..a..postsurgical..client..who..has..undergone..multiple..blood..trans
fusions,..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..-....
Correct..Answer-B
Rationale:
Multiple..blood..transfusions..are..a..risk..factor..for..hyperkalemia...A..serum..potass
ium..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..-....
Correct..Answer-A
Rationale:
The..hepatitis..B..vaccination..should..be..given..to..all..newborns..before..hospital..d
ischarge..(A)...HPV..is..not..recommended..until..adolescence..(B)...Varicella..immu
nization..begins..at..12..months..(C)...Meningococcal..vaccine..is..administered..beg
inning..at..2..years..(D).
The..nurse..is..caring..for..a..client..on..the..medical..unit...Which..task..can..be..delega
ted..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..regi
men...-....
Correct..Answer-B
,Rationale:
Obtaining..a..fingerstick..blood..glucose..level..is..a..simple..treatment..and..is..an..ap
propriate..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..prescriptio
n..for..tissue..plasminogen..activator..(t-
PA)..IV...Which..action(s)..should..the..nurse..expect..to..implement?..(Select..all..tha
t..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...-....
Correct..Answer-B,C,E
Rationale:
Neurologic..assessment,..including..the..NIHSS,..is..indicated..for..the..client..recei
ving..t-
PA...This..includes..close..monitoring..for..bleeding..during..and..after..the..infusion;
..if..bleeding..or..other..signs..of..neurologic..impairment..occur,..the..infusion..shoul
d..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..myocardia
l..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..-....
Correct..Answer-B
Rationale:
A..fetal..heart..rate..(FHR)..of..100..beats/min..may..indicate..fetal..distress..(B)..beca
use..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..l
abor.
The..nurse..is..caring..for..a..client..with..heart..failure..who..develops..respiratory..dis
tress..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...-....
Correct..Answer-C
Rationale:
Positioning..the..patient..in..a..high..Fowler's..position..with..dangling..feet..will..dec
rease..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)..PR
N.
B.Determine..if..the..client..has..increased..photosensitivity.
C.Provide..comfort..measures..for..sore..muscles.
