EXIT HESI COMPREHENSIVE B EVOLVE PRACTICE QUESTIONS
WITH ALL CORRECT & VERIFIED ANSWERS (UPDATED TO PASS)
1. The nurse is caring for a client newborn? A.Hepatitis B
with B.Human papilloma
a cerebrovascular accident (CVA) virus (HPV)
who is receiving enteral tube C.Varicella
feedings. D.Meningococcal vaccine
Which task performed by the UAP
re- quires 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 axil- lary method
D. Keeps head of bed
elevated at 30 degrees
2. When caring for a postsurgical
client who has undergone
multiple blood transfusions,
which serum laborato- ry
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
3. Which vaccination should the
nurse administer to a
, EXIT HESI COMPREHENSIVE B EVOLVE PRACTICE QUESTIONS
WITH ALL CORRECT & VERIFIED ANSWERS (UPDATED TO PASS)
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).
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).
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). Meningo-
, EXIT HESI COMPREHENSIVE B EVOLVE PRACTICE QUESTIONS
WITH ALL CORRECT & VERIFIED ANSWERS (UPDATED TO PASS)
coccal vaccine is administered beginning at 2
years (D).
4. The nurse is caring for a client B
on the medical unit. Which task Rationale:
can be dele- gated to unlicensed Obtaining a fingerstick blood glucose level is
assistive person- nel (UAP)? a 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 Rationale:
prescrip- tion for tissue Neurologic assessment, including the NIHSS,
plasminogen activator (t-PA) IV. is indicated for the client receiving t-PA. This
Which action(s) should the includes
nurse expect to implement? (Select all close monitoring for bleeding during
and after the
that apply.) (NIHSS).
A. Administer aspirin with C. Assess the client for
tissue plas- minogen activator signs of bleed- ing during
(t-PA). and after the infusion.
B. Complete the National D. Start t-PA within 6
Institute of Health Stroke Scale hours after the onset of
, EXIT HESI COMPREHENSIVE B EVOLVE PRACTICE QUESTIONS
WITH ALL CORRECT & VERIFIED ANSWERS (UPDATED TO PASS)
stroke symptoms. 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 in- farction and within 4.5
hours of symptoms is con- current for a
stroke (D).
WITH ALL CORRECT & VERIFIED ANSWERS (UPDATED TO PASS)
1. The nurse is caring for a client newborn? A.Hepatitis B
with B.Human papilloma
a cerebrovascular accident (CVA) virus (HPV)
who is receiving enteral tube C.Varicella
feedings. D.Meningococcal vaccine
Which task performed by the UAP
re- quires 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 axil- lary method
D. Keeps head of bed
elevated at 30 degrees
2. When caring for a postsurgical
client who has undergone
multiple blood transfusions,
which serum laborato- ry
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
3. Which vaccination should the
nurse administer to a
, EXIT HESI COMPREHENSIVE B EVOLVE PRACTICE QUESTIONS
WITH ALL CORRECT & VERIFIED ANSWERS (UPDATED TO PASS)
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).
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).
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). Meningo-
, EXIT HESI COMPREHENSIVE B EVOLVE PRACTICE QUESTIONS
WITH ALL CORRECT & VERIFIED ANSWERS (UPDATED TO PASS)
coccal vaccine is administered beginning at 2
years (D).
4. The nurse is caring for a client B
on the medical unit. Which task Rationale:
can be dele- gated to unlicensed Obtaining a fingerstick blood glucose level is
assistive person- nel (UAP)? a 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 Rationale:
prescrip- tion for tissue Neurologic assessment, including the NIHSS,
plasminogen activator (t-PA) IV. is indicated for the client receiving t-PA. This
Which action(s) should the includes
nurse expect to implement? (Select all close monitoring for bleeding during
and after the
that apply.) (NIHSS).
A. Administer aspirin with C. Assess the client for
tissue plas- minogen activator signs of bleed- ing during
(t-PA). and after the infusion.
B. Complete the National D. Start t-PA within 6
Institute of Health Stroke Scale hours after the onset of
, EXIT HESI COMPREHENSIVE B EVOLVE PRACTICE QUESTIONS
WITH ALL CORRECT & VERIFIED ANSWERS (UPDATED TO PASS)
stroke symptoms. 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 in- farction and within 4.5
hours of symptoms is con- current for a
stroke (D).
