EXIT HESI Comprehensive B Evolve Practice Questions
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
ANSW
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 fo
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
ANSW 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.
mEq/L indicates hyperkalemia (B). The others are normal findings (A, C, and D).
3. Which vaccination should the nurse administer to a newborn
ANSW 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 no
recommended until adolescence (B). Varicella immunization begins at 12 months (C). Meningococc
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)
ANSW
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
Rationale:
, EXIT HESI Comprehensive B Evolve Practice Questions
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
ANSW (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
ANSW
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
ANSW
A. Draw arterial blood gases.
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.: C
Rationale:
Positioning the patient in a high Fowler's position with dangling feet will decrease
, EXIT HESI Comprehensive B Evolve Practice Questions
further venous return to the left ventricle (C). The other actions should be performed after the change i
position (A, B, and D).
8. A client who is prescribed chlorpromazine HCl (Thorazine) for schizophre- nia develops rigidity, a
shuffling gait, and tremors. Which action by the nurse is most important
ANSWA.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.: A Rationale:
Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and mask- like face ar
extrapyramidal side effects associated with Thorazine. It is most im- portant for the nurse to administer a
anticholinergic such as Cogentin to reverse these effects (A). The others (B, C, D) may be appropria
interventions but are not as urgent as (A).
9. A nurse is interviewing a mother during a well-child visit. Which finding would alert the nurse to
continue further assessment of the infant
ANSW 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: B Rationale:
As a developmental milestone, infants should sit unsupported by 8 months (B). The milestone of rollin
over is achieved at 5 to 6 months for most infants (A). Stranger anxiety is common from 7 to 9 months (C
Speaking a few words is expected at about 12 months (D).
10. Which intervention should be included in the plan of care for a client admitted to the hospital
with ulcerative colitis
ANSW
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.: C Rationale:
A low-residue diet (C) will help decrease symptoms of diarrhea, which are clinical manifestations o
ulcerative colitis. (A, B, and D) are contraindicated and could worsen the condition.
11. The nurse is caring for a client with deep vein thrombosis who is on a continuous IV heparin
infusion. The activated partial prothrombin time (aPTT) is 120 seconds. Which action should the nurse
take
ANSW
, EXIT HESI Comprehensive B Evolve Practice Questions
A. Increase the rate of the heparin infusion using a nomogram.
B. Decrease the heparin infusion rate and give vitamin K IM.
C. Continue the heparin infusion at the current prescribed rate.
D. Stop the heparin drip and prepare to administer protamine sulfate.: D Rationale:
An aPTT more than 100 seconds is a critically high value; therefore, the heparin should be stopped. Th
antidote for heparin is protamine sulfate (D). Increasing the rate would increase the risk for hemorrhag
(A). The infusion should be stopped, and vitamin K is the antidote for warfarin (Coumadin) (B). Keepin
the infusion at the current rate would increase the risk for hemorrhage (C).
12. While assessing a client with recurring chest pain, the unit secretary notifies the nurse that the
client's health care provider is on the telephone. What action should the nurse instruct the unit
secretary to implement
ANSW
A. Transfer the call into the room of the client.
B. Instruct the secretary to explain reason for the call.
C. Ask another nurse to take the phone call.
D. Ask the health care provider to see the client on the unit.: C Rationale:
Another nurse should be asked to take the phone call (C), which allows the nurse to stay at the bedside to
complete the assessment of the client's chest pain. (A and B) should not be done during an acute change in
the client's condition. Requesting the health care provider (D) to come to the unit is premature until the
nurse completes assessment of the client's status.
13. 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)
ANSW (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).: 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).
