HESI EXIT COMPREHENSIVE B EVOLVE PRACTICE QUESTIONS AND
ANSWERS GRADED A+ 100% VERIFIED.
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
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, 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)?
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, 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
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, Rationale:
Obtaining a fingerstick blood glucose level is a simple treatment and is an appropri-
ate 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 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).
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ANSWERS GRADED A+ 100% VERIFIED.
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
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, 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)?
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, 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
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, Rationale:
Obtaining a fingerstick blood glucose level is a simple treatment and is an appropri-
ate 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 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).
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