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EXIT HESI Comprehensive B Evolve Practice (Latest Update 2025 / 2026) Questions with 100% Correct answers and Rationales [Grade A] - Nightingale

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EXIT HESI Comprehensive B Evolve Practice (Latest Update 2025 / 2026) Questions with 100% Correct answers and Rationales [Grade A] - Nightingale Which instruction(s) should the nurse include in the discharge teaching plan of a male client who has had a myocardial infarction and who has a new prescription for nitroglycerin (NTG)? (Select all that apply.) A.Keep the medication in your pocket so that it can be accessed quickly. B.Call 911 if chest pain is not relieved after one nitroglycerin. C.Store the medication in its original container and protect it from light. D.Activate the emergency medical system after three doses of medication. E.Do not use within 1 hour of taking sildenafil citrate (Viagra). - correct answer B,C Rationale: Emergency action should be taken if chest pain is not relieved after one nitroglycerin tablet (B). The medication should be kept in the original container to protect from light (C). Keeping the medication in the shirt pocket provides an environment that is too warm (A). The newest guidelines recommend calling 911 after one nitroglycerin tablet if chest pain is not relieved (D). Nitroglycerin and other nitrates should never be taken with Viagra (E). The nurse prepares to administer 3 units of regular insulin and 20 units of NPH insulin subcutaneously to a client with an elevated blood glucose level. Which procedure is correct? A.Using one syringe, first insert air into the regular vial and then insert air into the NPH vial. B.Using one syringe, add the regular insulin into the syringe and then add the NPH insulin. C.Avoid combining the two insulins because incompatibility could cause an adverse reaction. D.Administer the regular insulin subcutaneously and then give the NPH IV to prevent a separate stick. - correct answer B Rationale: The regular or "clear" insulin should be withdrawn into the syringe first, followed by the NPH (B). Air should first be injected into the NPH vial and then air should be inserted into the regular vial (A). NPH and regular insulin are compatible, and combining will reduce the number of injections (C). The insulin is ordered subcutaneously and NPH cannot be given IV (D). An 8-year-old child is receiving digoxin (Lanoxin) for congestive heart failure (CHF). In assessing the child, the nurse finds that her apical heart rate is 80 beats/min, she complains of being slightly nauseated, and her serum digoxin level is 1.2 ng/mL. What action should the nurse take? A.Because the child's heart rate and digoxin level are within normal range, assess for the cause of the nausea. B.Hold the next dose of digoxin until the health care provider can be notified because the serum digoxin level is elevated. C.Administer the next dose of digoxin and notify the health care provider that the child is showing signs of toxicity. D.Notify the health care provider that the child's pulse rate is below normal for her age group. - correct answer A Rationale: Nausea and vomiting are early signs of digoxin toxicity. However, the normal resting heart rate for a child 8 to 10 years of age is 70 to 110 beats/min and the therapeutic range of serum digoxin levels is 0.5 to 2 ng/mL. Based on the objective data, (A) is the best of the choices provided because the serum digoxin level is within normal levels. (B) is not warranted by the data presented. The digoxin level is within the therapeutic range and the child is not showing signs of toxicity (C). The child's pulse rate is within normal range for her age group (D). The nurse prepares to administer acetaminophen oral suspension to a child who weighs 66 pounds. The prescription reads: Administer 15 mg/kg every 6 hours by mouth. The Tylenol is available 150 mg/5 ml. Which is the correct dosage indicated on the image? A.30ml B.15ml C.10ml D.5ml - correct answer B Rationale: 66 lb/(2.2 kg/lb) = 30 kg 30 kg × (15 mg/kg) = 450 mg (5 mL/150 mg) × 450 mg = 15 mL or (450 mg/150 mg) × 5 mL = 15 mL

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Subido en
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EXIT HESI Comprehensive B Evolve
Practice (Latest Update )
Questions with 100% Correct answers and
Rationales [Grade A] - Nightingale



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) 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.

, EXIT HESI Comprehensive B Evolve
Practice (Latest Update )
Questions with 100% Correct answers and
Rationales [Grade A] - Nightingale


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 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. - correct answer A

Rationale:

, EXIT HESI Comprehensive B Evolve
Practice (Latest Update )
Questions with 100% Correct answers and
Rationales [Grade A] - Nightingale


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).




A nurse is interviewing a mother during a well-child visit. Which finding would alert

the nurse to continue further assessment of the infant?

A.Two-month-old who is unable to roll from back to abdomen

B.Ten-month-old who cannot sit without support

C.Nine-month-old who cries when his mother leaves the room

D.Eight-month-old who has not yet begun to speak words - correct answer B

Rationale:

As a developmental milestone, infants should sit unsupported by 8 months (B). The

milestone of rolling over is achieved at 5 to 6 months for most infants (A). Stranger

, EXIT HESI Comprehensive B Evolve
Practice (Latest Update )
Questions with 100% Correct answers and
Rationales [Grade A] - Nightingale


anxiety is common from 7 to 9 months (C). Speaking a few words is expected at

about 12 months (D).




Which intervention should be included in the plan of care for a client admitted to the

hospital with ulcerative colitis?

A.Administer stool softeners.

B.Place the client on fluid restriction.

C.Provide a low-residue diet.

D.Add a milk product to each meal. - correct answer C

Rationale:

A low-residue diet (C) will help decrease symptoms of diarrhea, which are clinical

manifestations of ulcerative colitis. (A, B, and D) are contraindicated and could

worsen the condition.
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