HESI RN Exit Exam Actual Exam 2026/2027 |
Questions with Verified Answers | 100% Correct |
Pass Guaranteed
SECTION 1: Fundamentals & Safe Care
Q1: A nurse on a medical-surgical unit receives report that a client has a new order for
contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) in a wound.
Which action should the nurse implement first?
A. Place the client in a private room with negative pressure ventilation
B. Don gloves and a gown before entering the client's room
C. Place a contact precautions sign on the client's door and provide staff education
D. Order a special respirator mask (N95) for all staff members
Correct Answer: C
Rationale: The priority is to prevent transmission by alerting staff and visitors. Placing
the sign and educating staff implements the first step in the transmission-based
precautions protocol. Option A is incorrect because negative pressure is for airborne
precautions, not contact. Option B is premature without first alerting staff. Option D is
unnecessary as MRSA requires contact, not airborne, precautions. According to CDC
guidelines, contact precautions signage is the initial implementation step before PPE
procurement or room placement.
Q2: During a safety rounds check, the nurse identifies that a confused elderly client has
a restraint order that expired 2 hours ago, but the client remains physically restrained.
What is the nurse's immediate priority action?
,A. Document the finding and notify the provider during rounds
B. Remove the restraints immediately while maintaining client safety
C. Have the UAP continue one-to-one observation until the order is renewed
D. Apply soft wrist restraints as a less restrictive alternative
Correct Answer: B
Rationale: Continuing restraints without a valid order is both a legal violation and an
unethical infringement on client autonomy (battery). The least restrictive principle and
Joint Commission standards mandate immediate removal. While maintaining safety is
critical, the nurse cannot legally or ethically leave restraints in place. Option A delays
necessary action. Option C is insufficient without also removing the illegal restraint.
Option D violates the requirement for a current physician order.
Q3: A nurse is preparing to administer 40 mEq of potassium chloride IV to a client with a
serum potassium of 2.8 mEq/L. Which safety check is most critical before
administration?
A. Verify the order and client identity using two identifiers
B. Ensure the IV bag contains at least 250 mL of fluid
C. Confirm the infusion will run at 10 mEq/hour via infusion pump
D. Assess that a central line is in place for potassium administration
Correct Answer: C
Rationale: The most critical safety check is the maximum safe infusion rate (no more
than 10 mEq/hour in a peripheral line, 20 mEq/hour in central line). Rapid potassium
infusion can cause fatal cardiac arrhythmias. While A and B are standard safety checks,
the rate is the specific life-threatening parameter for this high-alert medication. Option D
is incorrect because peripheral administration is acceptable at the proper rate with
cardiac monitoring.
Q4: The nurse discovers that a newly admitted client has a latex allergy. Which
intervention is the highest priority to ensure client safety?
,A. Place a latex allergy alert band on the client and document in the EHR
B. Stock the client's room with non-latex gloves and supplies
C. Notify dietary services to avoid latex-containing foods
D. Post latex allergy signs on the client's door and chart
Correct Answer: A
Rationale: The Joint Commission NPSG requires immediate identification and
communication of allergies. The allergy band is the first line of defense that travels with
the patient. While B, C, and D are essential components of the allergy plan, they cannot
be implemented without first identifying/denoting the allergy. The band ensures all staff
are alerted before any intervention.
Q5: A nurse is delegating morning care tasks to a UAP for four clients. Which task
assignment demonstrates appropriate delegation and supervision?
A. Have the UAP perform hourly neuro checks on a post-op craniotomy client
B. Assign the UAP to assist a stable post-op client with morning hygiene
C. Request the UAP to evaluate a client's chest tube drainage
D. Ask the UAP to feed a client with aspiration precautions who requires cues
Correct Answer: B
Rationale: According to the ANA delegation principles, UAPs can perform stable, routine
ADLs that don't require assessment or judgment. Option A violates scope as neuro
checks require RN assessment. Option C requires clinical evaluation beyond UAP scope.
Option D is unsafe as aspiration precautions require trained nursing assessment of
swallowing. The post-op client is stable, making hygiene an appropriate delegated task
with proper supervision.
Q6: A client is receiving a blood transfusion. Fifteen minutes after initiation, the nurse
notes the client is flushed, has chills, and a temperature increase from 98.6°F to
100.4°F. What is the nurse's first action?
A. Stop the transfusion immediately and maintain IV access with normal saline
, B. Slow the transfusion rate and administer antihistamines as ordered
C. Obtain a blood culture from the client
D. Continue the transfusion and document the reaction
Correct Answer: A
Rationale: Signs indicate a febrile non-hemolytic or potentially acute hemolytic reaction.
The immediate priority is to stop the transfusion (preventing more antigen/antibody
complexes) while preserving IV access for potential emergency medications. Option B
is unsafe as continuing the transfusion worsens the reaction. Option C is a later step in
the protocol after stopping the transfusion. Option D is negligent and life-threatening.
Q7: The nurse is caring for a client with a pulmonary artery catheter. Which assessment
finding requires immediate intervention?
A. Cardiac output reading of 4.5 L/min
B. Pulmonary artery wedge pressure of 12 mmHg
C. Blood-tinged fluid at the insertion site dressing
D. Client reports mild discomfort at insertion site
Correct Answer: C
Rationale: Blood-tinged fluid suggests catheter migration, sheath dislodgement, or
hemorrhage risk - all requiring immediate assessment for bleeding, pneumothorax, or
cardiac tamponade. PA catheter insertion sites are high-risk for lethal complications.
Option A is within normal range (4-8 L/min). Option B is normal (6-12 mmHg). Option D
is expected and not emergent.
Q8: When using clinical judgment to prioritize care for four clients, which client should
the nurse assess first?
A. Client requesting pain medication whose next dose is due in 30 minutes
B. Post-op client 2 hours post-surgery with a dry surgical dressing and vital signs stable
C. Client with a potassium level of 6.5 mEq/L who reports muscle weakness
D. Client with a blood glucose of 180 mg/dL scheduled for routine insulin coverage
Questions with Verified Answers | 100% Correct |
Pass Guaranteed
SECTION 1: Fundamentals & Safe Care
Q1: A nurse on a medical-surgical unit receives report that a client has a new order for
contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) in a wound.
Which action should the nurse implement first?
A. Place the client in a private room with negative pressure ventilation
B. Don gloves and a gown before entering the client's room
C. Place a contact precautions sign on the client's door and provide staff education
D. Order a special respirator mask (N95) for all staff members
Correct Answer: C
Rationale: The priority is to prevent transmission by alerting staff and visitors. Placing
the sign and educating staff implements the first step in the transmission-based
precautions protocol. Option A is incorrect because negative pressure is for airborne
precautions, not contact. Option B is premature without first alerting staff. Option D is
unnecessary as MRSA requires contact, not airborne, precautions. According to CDC
guidelines, contact precautions signage is the initial implementation step before PPE
procurement or room placement.
Q2: During a safety rounds check, the nurse identifies that a confused elderly client has
a restraint order that expired 2 hours ago, but the client remains physically restrained.
What is the nurse's immediate priority action?
,A. Document the finding and notify the provider during rounds
B. Remove the restraints immediately while maintaining client safety
C. Have the UAP continue one-to-one observation until the order is renewed
D. Apply soft wrist restraints as a less restrictive alternative
Correct Answer: B
Rationale: Continuing restraints without a valid order is both a legal violation and an
unethical infringement on client autonomy (battery). The least restrictive principle and
Joint Commission standards mandate immediate removal. While maintaining safety is
critical, the nurse cannot legally or ethically leave restraints in place. Option A delays
necessary action. Option C is insufficient without also removing the illegal restraint.
Option D violates the requirement for a current physician order.
Q3: A nurse is preparing to administer 40 mEq of potassium chloride IV to a client with a
serum potassium of 2.8 mEq/L. Which safety check is most critical before
administration?
A. Verify the order and client identity using two identifiers
B. Ensure the IV bag contains at least 250 mL of fluid
C. Confirm the infusion will run at 10 mEq/hour via infusion pump
D. Assess that a central line is in place for potassium administration
Correct Answer: C
Rationale: The most critical safety check is the maximum safe infusion rate (no more
than 10 mEq/hour in a peripheral line, 20 mEq/hour in central line). Rapid potassium
infusion can cause fatal cardiac arrhythmias. While A and B are standard safety checks,
the rate is the specific life-threatening parameter for this high-alert medication. Option D
is incorrect because peripheral administration is acceptable at the proper rate with
cardiac monitoring.
Q4: The nurse discovers that a newly admitted client has a latex allergy. Which
intervention is the highest priority to ensure client safety?
,A. Place a latex allergy alert band on the client and document in the EHR
B. Stock the client's room with non-latex gloves and supplies
C. Notify dietary services to avoid latex-containing foods
D. Post latex allergy signs on the client's door and chart
Correct Answer: A
Rationale: The Joint Commission NPSG requires immediate identification and
communication of allergies. The allergy band is the first line of defense that travels with
the patient. While B, C, and D are essential components of the allergy plan, they cannot
be implemented without first identifying/denoting the allergy. The band ensures all staff
are alerted before any intervention.
Q5: A nurse is delegating morning care tasks to a UAP for four clients. Which task
assignment demonstrates appropriate delegation and supervision?
A. Have the UAP perform hourly neuro checks on a post-op craniotomy client
B. Assign the UAP to assist a stable post-op client with morning hygiene
C. Request the UAP to evaluate a client's chest tube drainage
D. Ask the UAP to feed a client with aspiration precautions who requires cues
Correct Answer: B
Rationale: According to the ANA delegation principles, UAPs can perform stable, routine
ADLs that don't require assessment or judgment. Option A violates scope as neuro
checks require RN assessment. Option C requires clinical evaluation beyond UAP scope.
Option D is unsafe as aspiration precautions require trained nursing assessment of
swallowing. The post-op client is stable, making hygiene an appropriate delegated task
with proper supervision.
Q6: A client is receiving a blood transfusion. Fifteen minutes after initiation, the nurse
notes the client is flushed, has chills, and a temperature increase from 98.6°F to
100.4°F. What is the nurse's first action?
A. Stop the transfusion immediately and maintain IV access with normal saline
, B. Slow the transfusion rate and administer antihistamines as ordered
C. Obtain a blood culture from the client
D. Continue the transfusion and document the reaction
Correct Answer: A
Rationale: Signs indicate a febrile non-hemolytic or potentially acute hemolytic reaction.
The immediate priority is to stop the transfusion (preventing more antigen/antibody
complexes) while preserving IV access for potential emergency medications. Option B
is unsafe as continuing the transfusion worsens the reaction. Option C is a later step in
the protocol after stopping the transfusion. Option D is negligent and life-threatening.
Q7: The nurse is caring for a client with a pulmonary artery catheter. Which assessment
finding requires immediate intervention?
A. Cardiac output reading of 4.5 L/min
B. Pulmonary artery wedge pressure of 12 mmHg
C. Blood-tinged fluid at the insertion site dressing
D. Client reports mild discomfort at insertion site
Correct Answer: C
Rationale: Blood-tinged fluid suggests catheter migration, sheath dislodgement, or
hemorrhage risk - all requiring immediate assessment for bleeding, pneumothorax, or
cardiac tamponade. PA catheter insertion sites are high-risk for lethal complications.
Option A is within normal range (4-8 L/min). Option B is normal (6-12 mmHg). Option D
is expected and not emergent.
Q8: When using clinical judgment to prioritize care for four clients, which client should
the nurse assess first?
A. Client requesting pain medication whose next dose is due in 30 minutes
B. Post-op client 2 hours post-surgery with a dry surgical dressing and vital signs stable
C. Client with a potassium level of 6.5 mEq/L who reports muscle weakness
D. Client with a blood glucose of 180 mg/dL scheduled for routine insulin coverage
