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EXIT HESI COMPREHENSIVE B EVOLVE PRACTICE QUESTIONS AND ANSWERS WITH SOLUTIONS 2024
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EXIT HESI COMPREHENSIVE B EVOLVE PRACTICE QUESTIONS AND ANSWERS WITH SOLUTIONS 2024
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EXIT HESI COMPREHENSIVE B EVOLVEPRACTICE QUESTIONS AND ANSWERS
WITH SOLUTIONS 2024
TheJnurseJisJcaringJforJaJclientJwithJaJcerebrovascularJaccidentJ(CVA)JwhoJisJreceivingJenteralJtubeJfeedings.J
WhichJtaskJperformedJbyJtheJUAPJrequiresJimmediateJinterventionJbyJtheJnurse?
A.SuctionsJoralJsecretionsJfromJmouth
B.PositionsJheadJofJbedJflatJwhenJchangingJsheets
C.TakesJtemperatureJusingJtheJaxillaryJmethod
D.KeepsJheadJofJbedJelevatedJatJ30JdegreesJ-JANSWERJB
Rationale:
PositioningJtheJheadJofJtheJbedJflatJwhenJenteralJfeedingsJareJinJprogressJputsJtheJclientJatJriskJforJaspiratio
nJ(B).JTheJothersJareJallJacceptableJtasksJperformedJbyJtheJUAPJ(A,JC,JandJD).
WhenJcaringJforJaJpostsurgicalJclientJwhoJhasJundergoneJmultipleJbloodJtransfusions,JwhichJserumJlaborato
ryJfindingJisJofJmostJconcernJtoJtheJnurse?
A.SodiumJlevel,J137JmEq/L
B.PotassiumJlevel,J5.5JmEq/L
C.BloodJureaJnitrogenJ(BUN)Jlevel,J18Jmg/dL
D.CalciumJlevel,J10JmEq/LJ-JANSWERJB
Rationale:
MultipleJbloodJtransfusionsJareJaJriskJfactorJforJhyperkalemia.JAJserumJpotassiumJlevelJhigherJthanJ5.0JmEq
/LJindicatesJhyperkalemiaJ(B).JTheJothersJareJnormalJfindingsJ(A,JC,JandJD).
WhichJvaccinationJshouldJtheJnurseJadministerJtoJaJnewborn?
A.HepatitisJB
B.HumanJpapillomaJvirusJ(HPV)
C.Varicella
D.MeningococcalJvaccineJ-JANSWERJA
Rationale:
,TheJhepatitisJBJvaccinationJshouldJbeJgivenJtoJallJnewbornsJbeforeJhospitalJdischargeJ(A).JHPVJisJnotJrecom
mendedJuntilJadolescenceJ(B).JVaricellaJimmunizationJbeginsJatJ12JmonthsJ(C).JMeningococcalJvaccineJisJad
ministeredJbeginningJatJ2JyearsJ(D).
TheJnurseJisJcaringJforJaJclientJonJtheJmedicalJunit.JWhichJtaskJcanJbeJdelegatedJtoJunlicensedJassistiveJperso
nnelJ(UAP)?
A.AssessJtheJneedJtoJchangeJaJcentralJlineJdressing.
B.ObtainJaJfingerstickJbloodJglucoseJlevel.
C.AnswerJaJfamilyJmember'sJquestionsJaboutJtheJclient'sJplanJofJcare.
D.TeachJtheJclientJsideJeffectsJtoJreportJrelatedJtoJtheJcurrentJmedicationJregimen.J-JANSWERJB
Rationale:
ObtainingJaJfingerstickJbloodJglucoseJlevelJisJaJsimpleJtreatmentJandJisJanJappropriateJskillJforJUAPJtoJperfor
mJ(B).J(A,JC,JandJD)JareJskillsJthatJcannotJbeJdelegatedJtoJUAP.
TheJnurseJisJcaringJforJaJclientJwithJanJischemicJstrokeJwhoJhasJaJprescriptionJforJtissueJplasminogenJactivat
orJ(t-PA)JIV.JWhichJaction(s)JshouldJtheJnurseJexpectJtoJimplement?J(SelectJallJthatJapply.)
A.AdministerJaspirinJwithJtissueJplasminogenJactivatorJ(t-PA).
B.CompleteJtheJNationalJInstituteJofJHealthJStrokeJScaleJ(NIHSS).
C.AssessJtheJclientJforJsignsJofJbleedingJduringJandJafterJtheJinfusion.
D.StartJt-PAJwithinJ6JhoursJafterJtheJonsetJofJstrokeJsymptoms.
E.InitiateJmultidisciplinaryJconsultJforJpotentialJrehabilitation.J-JANSWERJB,C,E
Rationale:
NeurologicJassessment,JincludingJtheJNIHSS,JisJindicatedJforJtheJclientJreceivingJt-
PA.JThisJincludesJcloseJmonitoringJforJbleedingJduringJandJafterJtheJinfusion;JifJbleedingJorJotherJsignsJofJne
urologicJimpairmentJoccur,JtheJinfusionJshouldJbeJstoppedJ(B,JC,JandJE).JAspirinJisJcontraindicatedJwithJt-
PAJbecauseJitJincreasesJtheJriskJforJbleedingJ(A).JTheJadministrationJofJt-
PAJwithinJ6JhoursJofJsymptomsJisJconcurrentJwithJaJdiagnosisJofJaJmyocardialJinfarctionJandJwithinJ4.5Jhours
JofJsymptomsJisJconcurrentJforJaJstrokeJ(D).
WhenJcaringJforJaJclientJinJlabor,JwhichJfindingJisJmostJimportantJtoJreportJtoJtheJprimaryJhealthJcareJprovid
er?
A.MaternalJheartJrate,J90Jbeats/min.
B.FetalJheartJrate,J100Jbeats/min
,C.MaternalJbloodJpressure,J140/86JmmJHg
D.MaternalJtemperature,J100.0°JFJ-JANSWERJB
Rationale:
AJfetalJheartJrateJ(FHR)JofJ100Jbeats/minJmayJindicateJfetalJdistressJ(B)JbecauseJtheJaverageJFHRJatJtermJisJ1
40Jbeats/minJandJtheJnormalJrangeJisJ110JtoJbeats/minJ160.JTheJothersJ(A,JC,JandJD)JareJnormalJfindingsJforJ
aJwomanJinJlabor.
TheJnurseJisJcaringJforJaJclientJwithJheartJfailureJwhoJdevelopsJrespiratoryJdistressJandJcoughsJupJpinkJfrothy
Jsputum.JWhichJactionJshouldJtheJnurseJtakeJfirst?
A.DrawJarterialJbloodJgases.
B.NotifyJtheJprimaryJhealthJcareJprovider.
C.PositionJinJaJhighJFowler'sJpositionJwithJtheJlegsJdown.
D.ObtainJaJchestJX-ray.J-JANSWERJC
Rationale:
PositioningJtheJpatientJinJaJhighJFowler'sJpositionJwithJdanglingJfeetJwillJdecreaseJfurtherJvenousJreturnJtoJt
heJleftJventricleJ(C).JTheJotherJactionsJshouldJbeJperformedJafterJtheJchangeJinJpositionJ(A,JB,JandJD).
AJclientJwhoJisJprescribedJchlorpromazineJHClJ(Thorazine)JforJschizophreniaJdevelopsJrigidity,JaJshufflingJgai
t,JandJtremors.JWhichJactionJbyJtheJnurseJisJmostJimportant?A.AdministerJaJdoseJofJbenztropineJmesylateJ(
Cogentin)JPRN.
B.DetermineJifJtheJclientJhasJincreasedJphotosensitivity.
C.ProvideJcomfortJmeasuresJforJsoreJmuscles.
D.AssessJtheJclientJforJvisualJandJauditoryJhallucinations.J-JANSWERJA
Rationale:
Rigidity,JshufflingJgait,Jpill-
rollingJhandJmovements,Jtremors,Jdyskinesia,JandJmasklikeJfaceJareJextrapyramidalJsideJeffectsJassociatedJ
withJThorazine.JItJisJmostJimportantJforJtheJnurseJtoJadministerJanJanticholinergicJsuchJasJCogentinJtoJrevers
eJtheseJeffectsJ(A).JTheJothersJ(B,JC,JD)JmayJbeJappropriateJinterventionsJbutJareJnotJasJurgentJasJ(A).
AJnurseJisJinterviewingJaJmotherJduringJaJwell-
childJvisit.JWhichJfindingJwouldJalertJtheJnurseJtoJcontinueJfurtherJassessmentJofJtheJinfant?
A.Two-month-oldJwhoJisJunableJtoJrollJfromJbackJtoJabdomen
, B.Ten-month-oldJwhoJcannotJsitJwithoutJsupport
C.Nine-month-oldJwhoJcriesJwhenJhisJmotherJleavesJtheJroom
D.Eight-month-oldJwhoJhasJnotJyetJbegunJtoJspeakJwordsJ-JANSWERJB
Rationale:
AsJaJdevelopmentalJmilestone,JinfantsJshouldJsitJunsupportedJbyJ8JmonthsJ(B).JTheJmilestoneJofJrollingJover
JisJachievedJatJ5JtoJ6JmonthsJforJmostJinfantsJ(A).JStrangerJanxietyJisJcommonJfromJ7JtoJ9JmonthsJ(C).JSpeaki
ngJaJfewJwordsJisJexpectedJatJaboutJ12JmonthsJ(D).
WhichJinterventionJshouldJbeJincludedJinJtheJplanJofJcareJforJaJclientJadmittedJtoJtheJhospitalJwithJulcerativ
eJcolitis?
A.AdministerJstoolJsofteners.
B.PlaceJtheJclientJonJfluidJrestriction.
C.ProvideJaJlow-residueJdiet.
D.AddJaJmilkJproductJtoJeachJmeal.J-JANSWERJC
Rationale:
AJlow-
residueJdietJ(C)JwillJhelpJdecreaseJsymptomsJofJdiarrhea,JwhichJareJclinicalJmanifestationsJofJulcerativeJcolit
is.J(A,JB,JandJD)JareJcontraindicatedJandJcouldJworsenJtheJcondition.
TheJnurseJisJcaringJforJaJclientJwithJdeepJveinJthrombosisJwhoJisJonJaJcontinuousJIVJheparinJinfusion.JTheJact
ivatedJpartialJprothrombinJtimeJ(aPTT)JisJ120Jseconds.JWhichJactionJshouldJtheJnurseJtake?
A.IncreaseJtheJrateJofJtheJheparinJinfusionJusingJaJnomogram.
B.DecreaseJtheJheparinJinfusionJrateJandJgiveJvitaminJKJIM.
C.ContinueJtheJheparinJinfusionJatJtheJcurrentJprescribedJrate.
D.StopJtheJheparinJdripJandJprepareJtoJadministerJprotamineJsulfate.J-JANSWERJD
Rationale:
AnJaPTTJmoreJthanJ100JsecondsJisJaJcriticallyJhighJvalue;Jtherefore,JtheJheparinJshouldJbeJstopped.JTheJanti
doteJforJheparinJisJprotamineJsulfateJ(D).JIncreasingJtheJrateJwouldJincreaseJtheJriskJforJhemorrhageJ(A).JTh
eJinfusionJshouldJbeJstopped,JandJvitaminJKJisJtheJantidoteJforJwarfarinJ(Coumadin)J(B).JKeepingJtheJinfusio
nJatJtheJcurrentJrateJwouldJincreaseJtheJriskJforJhemorrhageJ(C).
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