HESI EXIT COMPREHENSIVE B EVOLVE PRACTICE
VERIFIED QUESTIONS
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 - ANSWERS-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).
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 - ANSWERS-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).
Which vaccination should the nurse administer to a newborn?
A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
D.Meningococcal vaccine - ANSWERS-A
Rationale:
The hepatitis B vaccination should be given to all newborns before hospital discharge
(A). HPV is not recommended until adolescence (B). Varicella immunization begins at
12 months (C). Meningococcal vaccine is administered beginning at 2 years (D).
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.
D.Teach the client side effects to report related to the current medication regimen. -
ANSWERS-B
Rationale