10/18/24, 8:48 AM EXIT HESI Comprehensive B Evolve Practice Questions/EXIT HESI Comprehensive B Evolve Practice Questions and Answe…
EXIT HESI Comprehensive B Evolve Practice
Questions/EXIT HESI Comprehensive B Evolve
Practice Questions and Answers Latest
2024/2025 update
Terms in this set (100)
The nurse is caring for a B
client with a Rationale:
cerebrovascular accident Positioning the head of the bed flat when enteral
(CVA) who is receiving feedings are in progress puts the client at risk for
enteral tube feedings. aspiration (B). The others are all acceptable tasks
Which task performed by performed by the UAP (A, C, and D).
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
,10/18/24, 8:48 AM EXIT HESI Comprehensive B Evolve Practice Questions/EXIT HESI Comprehensive B Evolve Practice Questions and Answe…
When caring for a B
postsurgical client who Rationale:
has undergone multiple Multiple blood transfusions are a risk factor for
blood transfusions, which hyperkalemia. A serum potassium level higher than
serum laboratory finding 5.0 mEq/L indicates hyperkalemia (B). The others are
is of most concern to the normal findings (A, C, and D).
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
Which vaccination should A
the nurse administer to a Rationale:
newborn? The hepatitis B vaccination should be given to all
A.Hepatitis B newborns before hospital discharge (A). HPV is not
B.Human papilloma virus recommended until adolescence (B). Varicella
(HPV) immunization begins at 12 months (C).
C.Varicella Meningococcal vaccine is administered beginning at
D.Meningococcal 2 years (D).
vaccine
,10/18/24, 8:48 AM EXIT HESI Comprehensive B Evolve Practice Questions/EXIT HESI Comprehensive B Evolve Practice Questions and Answe…
The nurse is caring for a B
client on the medical unit. Rationale:
Which task can be Obtaining a fingerstick blood glucose level is a
delegated to unlicensed simple treatment and is an appropriate skill for UAP
assistive personnel to perform (B). (A, C, and D) are skills that cannot be
(UAP)? delegated to 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.
D.Teach the client side
effects to report related
to the current medication
regimen.
, 10/18/24, 8:48 AM EXIT HESI Comprehensive B Evolve Practice Questions/EXIT HESI Comprehensive B Evolve Practice Questions and Answe…
The nurse is caring for a B,C,E
client with an ischemic Rationale:
stroke who has a Neurologic assessment, including the NIHSS, is
prescription for tissue indicated for the client receiving t-PA. This includes
plasminogen activator (t- close monitoring for bleeding during and after the
PA) IV. Which action(s) infusion; if bleeding or other signs of neurologic
should the nurse expect impairment occur, the infusion should be stopped
to implement? (Select all (B, C, and E). Aspirin is contraindicated with t-PA
that apply.) because it increases the risk for bleeding (A). The
A.Administer aspirin with administration of t-PA within 6 hours of symptoms is
tissue plasminogen concurrent with a diagnosis of a myocardial
activator (t-PA). infarction and within 4.5 hours of symptoms is
B.Complete the National concurrent for a stroke (D).
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.
When caring for a client B
in labor, which finding is Rationale:
most important to report A fetal heart rate (FHR) of 100 beats/min may
to the primary health indicate fetal distress (B) because the average FHR
care provider? at term is 140 beats/min and the normal range is 110
A.Maternal heart rate, 90 to beats/min 160. The others (A, C, and D) are
beats/min. normal findings for a woman in labor.
B.Fetal heart rate, 100
beats/min
C.Maternal blood
pressure, 140/86 mm Hg
D.Maternal temperature,
100.0° F
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