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 temper...
EXIT HESI Comprehensive B Evolve ACTUAL EXAM 2023 GRADED
A+
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 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 immunizatio
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)?
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.
, EXIT HESI Comprehensive B Evolve ACTUAL EXAM 2023 GRADED
D.Teach
A+the client side effects to report related to the current medication
, EXIT HESI Comprehensive B Evolve Practice
Questions
regimen.: B
Rationale:
Obtaining a fingerstick blood glucose level is a simple treatment and is an appro-
priate 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).
6. 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: 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.
7. 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.
, EXIT HESI Comprehensive B Evolve Practice
D.Obtain a chest X-ray.: C
Questions
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