2026 HESI PN EXIT EXAM V1-V7 |
Questions & Answers | Verified
Revised Full Exam | Practical Nursing
| Pass Guaranteed - A+ Graded
# HESI PN EXIT EXAM VERSION 1 (75 Questions)
## DOMAIN 1: SAFE AND EFFECTIVE CARE ENVIRONMENT (18 Questions)
### Management of Care
* *1. A nurse is caring for four clients on a medical-surgical unit. Which task should the nurse
delegate to the unlicensed assistive personnel (UAP)?**
- A. Administering oral medications to a stable client
- B. Measuring and recording intake and output for all assigned clients **[CORRECT]**
- C. Assessing a postoperative client's incision for signs of infection
- D. Teaching a newly diagnosed diabetic client about insulin administration
* *Rationale:** The nurse may delegate tasks that are routine, repetitive, and do not require
nursing judgment. Measuring I&O is within the UAP scope of practice. Medication
administration, patient assessment, and patient teaching require nursing licensure and cannot
be delegated.
---
* *2. A client is scheduled for an elective cholecystectomy. Who is responsible for explaining the
procedure and obtaining informed consent?**
- A. The nurse admitting the client
- B. The surgeon performing the procedure **[CORRECT]**
- C. The anesthesiologist
- D. The hospital administrator
* *Rationale:** The surgeon performing the procedure is legally responsible for explaining the
risks, benefits, and alternatives and obtaining informed consent. The nurse may witness the
signature but is not responsible for the explanation.
---
,* *3. A nurse enters a client's room and finds the client on the floor. The client states, "I fell when
trying to get to the bathroom." What is the nurse's priority action after ensuring client safety?**
- A. Call the physician immediately
- B. Complete an incident report **[CORRECT]**
- C. Document the fall in the medical record
- D. Notify the family first
* *Rationale:** An incident report (also called a variance report) must be completed for any error,
accident, or unexpected event. This is used for quality improvement and risk management
purposes. Documentation in the medical record should be factual and objective, without
referencing the incident report.
---
* *4. A nurse is using SBAR to communicate with the physician about a client's deteriorating
condition. What does the "R" in SBAR represent?**
- A. Reason for the call
- B. Recommendation **[CORRECT]**
- C. Response to treatment
- D. Review of systems
* *Rationale:** SBAR stands for Situation, Background, Assessment, and Recommendation. The
recommendation component includes what action the nurse is requesting or what problem
needs to be addressed.
---
* *5. A client with terminal cancer has a living will stating they do not want artificial nutrition or
hydration. The family insists on placing a feeding tube. What is the nurse's best action?**
- A. Insert the feeding tube as the family requests
- B. Honor the living will and notify the physician and ethics committee **[CORRECT]**
- C. Ask the client to change the living will
- D. Follow the family's wishes since they are the decision-makers
* *Rationale:** A living will is an advance directive that describes the client's desires regarding
end-of-life care. It is legally binding when the client lacks decision-making capacity. The nurse
must advocate for the client's documented wishes.
---
* *6. A nurse overhears two colleagues discussing a client's HIV status in the cafeteria. What is
the nurse's legal obligation?**
- A. Ignore it since the cafeteria is a private area
,- B. Report the breach of confidentiality to the nurse manager **[CORRECT]**
- C. Confront the colleagues publicly
- D. Document the incident in the client's chart
* *Rationale:** HIPAA protects patient health information. Discussion of protected health
information in public areas violates confidentiality. The nurse must report this breach to protect
the client and ensure institutional compliance.
---
* *7. Which task is appropriate for the nurse to delegate to a licensed practical nurse (LPN)?**
- A. Developing a plan of care for a newly admitted client
- B. Administering oral medications to stable clients **[CORRECT]**
- C. Performing the initial assessment on a postoperative client
- D. Teaching a client about wound care before discharge
* *Rationale:** LPNs can administer medications (oral, topical, subcutaneous, intramuscular) to
stable clients with predictable outcomes. Initial assessments, care planning, and patient
teaching require RN-level judgment and education.
---
### Safety and Infection Control
* *8. A nurse is caring for four clients. Which client should the nurse assess first?**
- A. A client with diabetes requesting a snack
- B. A client with pneumonia whose oxygen saturation is 88% **[CORRECT]**
- C. A client scheduled for discharge who needs discharge teaching
- D. A client with hypertension whose blood pressure is 150/90 mmHg
* *Rationale:** Using the ABCs (Airway, Breathing, Circulation) prioritization framework, the client
with low oxygen saturation (normal is 95-100%) requires immediate assessment. This
represents a potential life-threatening situation.
---
* *9. A confused client keeps pulling at their IV line. What is the least restrictive intervention the
nurse should implement first?**
- A. Apply wrist restraints
- B. Cover the IV site with a protective sleeve **[CORRECT]**
- C. Sedate the client with PRN medication
- D. Assign a sitter to watch the client constantly
, * *Rationale:** The least restrictive intervention should always be used first. Covering the IV site
protects the line while allowing the client freedom of movement. Restraints require a physician's
order and frequent monitoring.
---
* *10. A fire breaks out in a client's room. According to the RACE protocol, what is the nurse's
first action?**
- A. Activate the alarm and Alert others **[CORRECT]**
- B. Confine the fire by closing doors
- C. Extinguish the fire if possible
- D. Evacuate clients from the area
* *Rationale:** RACE stands for Rescue/Remove, Alarm/Alert, Confine, and
Extinguish/Evacuate. The first step is to rescue any clients in immediate danger, then activate
the alarm system to alert others.
---
* *11. Which action demonstrates proper surgical asepsis when setting up a sterile field?**
- A. Placing the sterile field on the overbed table at waist level
- B. Keeping the sterile field above waist level at all times **[CORRECT]**
- C. Reaching across the sterile field to obtain supplies
- D. Turning back to the sterile field after facing away briefly
* *Rationale:** Sterile fields must be kept above waist level because areas below the waist are
considered contaminated. Once a sterile field is established, the nurse must not reach across it
or turn away from it.
---
* *12. A nurse is caring for a client with Clostridioides difficile (C. diff) infection. What type of
precautions are required?**
- A. Droplet precautions
- B. Airborne precautions
- C. Contact precautions **[CORRECT]**
- D. Standard precautions only
* *Rationale:** C. diff is transmitted via contact with contaminated surfaces or hands. Contact
precautions require gown and gloves for room entry and dedicated equipment for the client.
---
Questions & Answers | Verified
Revised Full Exam | Practical Nursing
| Pass Guaranteed - A+ Graded
# HESI PN EXIT EXAM VERSION 1 (75 Questions)
## DOMAIN 1: SAFE AND EFFECTIVE CARE ENVIRONMENT (18 Questions)
### Management of Care
* *1. A nurse is caring for four clients on a medical-surgical unit. Which task should the nurse
delegate to the unlicensed assistive personnel (UAP)?**
- A. Administering oral medications to a stable client
- B. Measuring and recording intake and output for all assigned clients **[CORRECT]**
- C. Assessing a postoperative client's incision for signs of infection
- D. Teaching a newly diagnosed diabetic client about insulin administration
* *Rationale:** The nurse may delegate tasks that are routine, repetitive, and do not require
nursing judgment. Measuring I&O is within the UAP scope of practice. Medication
administration, patient assessment, and patient teaching require nursing licensure and cannot
be delegated.
---
* *2. A client is scheduled for an elective cholecystectomy. Who is responsible for explaining the
procedure and obtaining informed consent?**
- A. The nurse admitting the client
- B. The surgeon performing the procedure **[CORRECT]**
- C. The anesthesiologist
- D. The hospital administrator
* *Rationale:** The surgeon performing the procedure is legally responsible for explaining the
risks, benefits, and alternatives and obtaining informed consent. The nurse may witness the
signature but is not responsible for the explanation.
---
,* *3. A nurse enters a client's room and finds the client on the floor. The client states, "I fell when
trying to get to the bathroom." What is the nurse's priority action after ensuring client safety?**
- A. Call the physician immediately
- B. Complete an incident report **[CORRECT]**
- C. Document the fall in the medical record
- D. Notify the family first
* *Rationale:** An incident report (also called a variance report) must be completed for any error,
accident, or unexpected event. This is used for quality improvement and risk management
purposes. Documentation in the medical record should be factual and objective, without
referencing the incident report.
---
* *4. A nurse is using SBAR to communicate with the physician about a client's deteriorating
condition. What does the "R" in SBAR represent?**
- A. Reason for the call
- B. Recommendation **[CORRECT]**
- C. Response to treatment
- D. Review of systems
* *Rationale:** SBAR stands for Situation, Background, Assessment, and Recommendation. The
recommendation component includes what action the nurse is requesting or what problem
needs to be addressed.
---
* *5. A client with terminal cancer has a living will stating they do not want artificial nutrition or
hydration. The family insists on placing a feeding tube. What is the nurse's best action?**
- A. Insert the feeding tube as the family requests
- B. Honor the living will and notify the physician and ethics committee **[CORRECT]**
- C. Ask the client to change the living will
- D. Follow the family's wishes since they are the decision-makers
* *Rationale:** A living will is an advance directive that describes the client's desires regarding
end-of-life care. It is legally binding when the client lacks decision-making capacity. The nurse
must advocate for the client's documented wishes.
---
* *6. A nurse overhears two colleagues discussing a client's HIV status in the cafeteria. What is
the nurse's legal obligation?**
- A. Ignore it since the cafeteria is a private area
,- B. Report the breach of confidentiality to the nurse manager **[CORRECT]**
- C. Confront the colleagues publicly
- D. Document the incident in the client's chart
* *Rationale:** HIPAA protects patient health information. Discussion of protected health
information in public areas violates confidentiality. The nurse must report this breach to protect
the client and ensure institutional compliance.
---
* *7. Which task is appropriate for the nurse to delegate to a licensed practical nurse (LPN)?**
- A. Developing a plan of care for a newly admitted client
- B. Administering oral medications to stable clients **[CORRECT]**
- C. Performing the initial assessment on a postoperative client
- D. Teaching a client about wound care before discharge
* *Rationale:** LPNs can administer medications (oral, topical, subcutaneous, intramuscular) to
stable clients with predictable outcomes. Initial assessments, care planning, and patient
teaching require RN-level judgment and education.
---
### Safety and Infection Control
* *8. A nurse is caring for four clients. Which client should the nurse assess first?**
- A. A client with diabetes requesting a snack
- B. A client with pneumonia whose oxygen saturation is 88% **[CORRECT]**
- C. A client scheduled for discharge who needs discharge teaching
- D. A client with hypertension whose blood pressure is 150/90 mmHg
* *Rationale:** Using the ABCs (Airway, Breathing, Circulation) prioritization framework, the client
with low oxygen saturation (normal is 95-100%) requires immediate assessment. This
represents a potential life-threatening situation.
---
* *9. A confused client keeps pulling at their IV line. What is the least restrictive intervention the
nurse should implement first?**
- A. Apply wrist restraints
- B. Cover the IV site with a protective sleeve **[CORRECT]**
- C. Sedate the client with PRN medication
- D. Assign a sitter to watch the client constantly
, * *Rationale:** The least restrictive intervention should always be used first. Covering the IV site
protects the line while allowing the client freedom of movement. Restraints require a physician's
order and frequent monitoring.
---
* *10. A fire breaks out in a client's room. According to the RACE protocol, what is the nurse's
first action?**
- A. Activate the alarm and Alert others **[CORRECT]**
- B. Confine the fire by closing doors
- C. Extinguish the fire if possible
- D. Evacuate clients from the area
* *Rationale:** RACE stands for Rescue/Remove, Alarm/Alert, Confine, and
Extinguish/Evacuate. The first step is to rescue any clients in immediate danger, then activate
the alarm system to alert others.
---
* *11. Which action demonstrates proper surgical asepsis when setting up a sterile field?**
- A. Placing the sterile field on the overbed table at waist level
- B. Keeping the sterile field above waist level at all times **[CORRECT]**
- C. Reaching across the sterile field to obtain supplies
- D. Turning back to the sterile field after facing away briefly
* *Rationale:** Sterile fields must be kept above waist level because areas below the waist are
considered contaminated. Once a sterile field is established, the nurse must not reach across it
or turn away from it.
---
* *12. A nurse is caring for a client with Clostridioides difficile (C. diff) infection. What type of
precautions are required?**
- A. Droplet precautions
- B. Airborne precautions
- C. Contact precautions **[CORRECT]**
- D. Standard precautions only
* *Rationale:** C. diff is transmitted via contact with contaminated surfaces or hands. Contact
precautions require gown and gloves for room entry and dedicated equipment for the client.
---
