EXIT HESI Comprehensive B
Evolve EXAM STUDY GUIDE.
GRADED A+. QUESTIONS AND
100% VERIFIED ANSWERS.
LATEST 2026 UPDATE
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 - Ans✔✔-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).
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 - Ans✔✔-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).
Which vaccination should the nurse administer to a newborn?
A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
D.Meningococcal vaccine - Ans✔✔-A
Rationale:
The hepatitis B vaccination should be given to all newborns before hospital
discharge (A). HPV is not recommended until adolescence (B). Varicella
immunization begins at 12 months (C). Meningococcal vaccine is administered
beginning at 2 years (D).
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. - Ans✔✔-B
Rationale:
,Obtaining a fingerstick blood glucose level is a simple treatment and is an
appropriate 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 prescription
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. - Ans✔✔-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 occur, the infusion should
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 myocardial 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 - Ans✔✔-B
Rationale:
, A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress (B) because
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
labor.
The nurse is caring for a client with heart failure who develops respiratory
distress 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. - Ans✔✔-C
Rationale:
Positioning the patient in a high Fowler's position with dangling feet will
decrease 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) PRN.
B.Determine if the client has increased photosensitivity.
C.Provide comfort measures for sore muscles.
D.Assess the client for visual and auditory hallucinations. - Ans✔✔-A
Rationale:
Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and
masklike face are extrapyramidal side effects associated with Thorazine. It is
most important for the nurse to administer an anticholinergic such as Cogentin
to reverse these effects (A). The others (B, C, D) may be appropriate
interventions but are not as urgent as (A).
Evolve EXAM STUDY GUIDE.
GRADED A+. QUESTIONS AND
100% VERIFIED ANSWERS.
LATEST 2026 UPDATE
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 - Ans✔✔-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).
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 - Ans✔✔-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).
Which vaccination should the nurse administer to a newborn?
A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
D.Meningococcal vaccine - Ans✔✔-A
Rationale:
The hepatitis B vaccination should be given to all newborns before hospital
discharge (A). HPV is not recommended until adolescence (B). Varicella
immunization begins at 12 months (C). Meningococcal vaccine is administered
beginning at 2 years (D).
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. - Ans✔✔-B
Rationale:
,Obtaining a fingerstick blood glucose level is a simple treatment and is an
appropriate 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 prescription
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. - Ans✔✔-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 occur, the infusion should
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 myocardial 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 - Ans✔✔-B
Rationale:
, A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress (B) because
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
labor.
The nurse is caring for a client with heart failure who develops respiratory
distress 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. - Ans✔✔-C
Rationale:
Positioning the patient in a high Fowler's position with dangling feet will
decrease 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) PRN.
B.Determine if the client has increased photosensitivity.
C.Provide comfort measures for sore muscles.
D.Assess the client for visual and auditory hallucinations. - Ans✔✔-A
Rationale:
Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and
masklike face are extrapyramidal side effects associated with Thorazine. It is
most important for the nurse to administer an anticholinergic such as Cogentin
to reverse these effects (A). The others (B, C, D) may be appropriate
interventions but are not as urgent as (A).
