HESI RN SAFETY ACCURATE COMPREHENSIVE
PRACTICE EXAM WITH ALL POSSIBLE APPROVED
WELL ELABORATED PRACTICE QUESTIONS AND
100% CORRECT VERIFIED ANSWERS WITH
DETAILED RATIONALES PLUS EXPERT ANSWER
KEY (100% CORRECT VERIFIED SOLUTIONS) 2026-
2027 CURRENTLY UPDATED VERSION Q&A
GUARANTEED PASS A+ INSTANT DOWNLOAD PDF
Question 1
A client is prescribed a continuous IV infusion of heparin. Which
laboratory value is the most critical for the nurse to monitor to ensure
patient safety?
A. Platelet count
B. Activated partial thromboplastin time (aPTT)
C. Prothrombin time (PT)
D. International normalized ratio (INR)
Correct Answer: B
Rationale: The aPTT is the primary lab value used to monitor the
effectiveness and safety of heparin therapy. The therapeutic range for
heparin is typically 1.5 to 2.5 times the control value. Monitoring
platelet counts is also important to detect heparin-induced
,thrombocytopenia (HIT), but aPTT is the direct measure of the drug's
anticoagulant effect. PT and INR are used to monitor warfarin therapy.
Question 2
A nurse is preparing to administer an enteral feeding through a
nasogastric (NG) tube. Which action should the nurse take first to
ensure patient safety?
A. Flush the tube with 30 mL of water
B. Verify tube placement by checking the pH of aspirated fluid
C. Elevate the head of the bed to 30 degrees
D. Confirm the tube is secured to the patient's gown
Correct Answer: B
Rationale: The first and most critical step before administering any
enteral feeding is to verify correct NG tube placement. Checking the pH
of aspirated fluid (typically ≤ 5 for gastric placement) is a reliable
method. Auscultation is no longer recommended as a sole method.
While flushing, elevating the HOB, and securing the tube are important,
placement verification is paramount to prevent accidental pulmonary
administration.
Question 3
A client on a medical-surgical unit has a new order for wrist restraints.
Which action by the nurse is essential for safe restraint use?
A. Apply the restraints tightly to prevent the client from loosening them
B. Tie the restraints to the bed frame using a quick-release knot
C. Document the client's behavior every 4 hours
D. Remove the restraints every 4 hours for range of motion exercises
Correct Answer: B
Rationale: Restraints must be tied to a non-movable part of the bed
frame with a quick-release knot to allow for rapid removal in an
emergency. They should be applied snugly but not tight enough to
,impede circulation. Documentation must be more frequent (at least
every 1-2 hours) and include attempts to release, and restraints must be
removed every 2 hours for ROM and assessment, not 4.
Question 4
A nurse is caring for a client who is at risk for falls. Which intervention is
most effective for preventing falls?
A. Keep the bed in the lowest position with all side rails up
B. Place the call light within the client's reach
C. Encourage the client to wear nonskid socks or footwear
D. Use a bed alarm system
Correct Answer: C
Rationale: While all options are components of a fall prevention plan,
encouraging the use of nonskid footwear directly addresses the
common mechanism of falls—slipping on smooth surfaces. A multi-
faceted approach is best, but this is a fundamental, direct intervention.
Keeping all side rails up can be a restraint and increase fall risk if the
client tries to climb over them. A bed alarm is a monitoring tool, not a
prevention strategy in itself.
Question 5
The nurse is administering medications to a client and notes that the
client has an allergy to penicillin, but a prescription for amoxicillin is
present. What is the nurse's priority action?
A. Administer the amoxicillin as prescribed
B. Contact the healthcare provider to clarify the prescription
C. Ask the client about the type of reaction they had to penicillin
D. Hold the medication and document the allergy in the medical record
Correct Answer: B
Rationale: This is a critical safety issue. Amoxicillin is a penicillin-class
antibiotic and is contraindicated in clients with a true penicillin allergy
, due to cross-reactivity. The nurse's priority is to contact the healthcare
provider immediately to question the prescription, prevent a potential
anaphylactic reaction, and get a new order. The medication must be
held. Documenting the allergy is important but is a secondary action
after addressing the immediate risk.
Question 6
A client is receiving a blood transfusion. Fifteen minutes after the start
of the infusion, the client reports chills and low back pain. What is the
nurse's first action?
A. Slow the infusion rate and reassess in 15 minutes
B. Stop the transfusion and disconnect the IV tubing
C. Stop the transfusion and infuse normal saline with new tubing
D. Administer diphenhydramine (Benadryl) as prescribed
Correct Answer: C
Rationale: These are classic signs of a hemolytic transfusion reaction.
The nurse must immediately stop the transfusion, but also must keep
the IV line open with normal saline and new tubing to maintain venous
access for emergency medications. The blood tubing and bag are then
sent to the blood bank. Slowing the infusion is incorrect and dangerous.
Disconnecting the tubing would lose IV access.
Question 7
Which action by the nursing assistant requires immediate intervention
by the supervising nurse?
A. Placing a client in bed with the side rails up and the bed in the lowest
position
B. Applying a warm compress to a client's IV site without a provider
order
C. Repositioning a client who is on fall precautions every 2 hours
D. Measuring a client's intake and output
PRACTICE EXAM WITH ALL POSSIBLE APPROVED
WELL ELABORATED PRACTICE QUESTIONS AND
100% CORRECT VERIFIED ANSWERS WITH
DETAILED RATIONALES PLUS EXPERT ANSWER
KEY (100% CORRECT VERIFIED SOLUTIONS) 2026-
2027 CURRENTLY UPDATED VERSION Q&A
GUARANTEED PASS A+ INSTANT DOWNLOAD PDF
Question 1
A client is prescribed a continuous IV infusion of heparin. Which
laboratory value is the most critical for the nurse to monitor to ensure
patient safety?
A. Platelet count
B. Activated partial thromboplastin time (aPTT)
C. Prothrombin time (PT)
D. International normalized ratio (INR)
Correct Answer: B
Rationale: The aPTT is the primary lab value used to monitor the
effectiveness and safety of heparin therapy. The therapeutic range for
heparin is typically 1.5 to 2.5 times the control value. Monitoring
platelet counts is also important to detect heparin-induced
,thrombocytopenia (HIT), but aPTT is the direct measure of the drug's
anticoagulant effect. PT and INR are used to monitor warfarin therapy.
Question 2
A nurse is preparing to administer an enteral feeding through a
nasogastric (NG) tube. Which action should the nurse take first to
ensure patient safety?
A. Flush the tube with 30 mL of water
B. Verify tube placement by checking the pH of aspirated fluid
C. Elevate the head of the bed to 30 degrees
D. Confirm the tube is secured to the patient's gown
Correct Answer: B
Rationale: The first and most critical step before administering any
enteral feeding is to verify correct NG tube placement. Checking the pH
of aspirated fluid (typically ≤ 5 for gastric placement) is a reliable
method. Auscultation is no longer recommended as a sole method.
While flushing, elevating the HOB, and securing the tube are important,
placement verification is paramount to prevent accidental pulmonary
administration.
Question 3
A client on a medical-surgical unit has a new order for wrist restraints.
Which action by the nurse is essential for safe restraint use?
A. Apply the restraints tightly to prevent the client from loosening them
B. Tie the restraints to the bed frame using a quick-release knot
C. Document the client's behavior every 4 hours
D. Remove the restraints every 4 hours for range of motion exercises
Correct Answer: B
Rationale: Restraints must be tied to a non-movable part of the bed
frame with a quick-release knot to allow for rapid removal in an
emergency. They should be applied snugly but not tight enough to
,impede circulation. Documentation must be more frequent (at least
every 1-2 hours) and include attempts to release, and restraints must be
removed every 2 hours for ROM and assessment, not 4.
Question 4
A nurse is caring for a client who is at risk for falls. Which intervention is
most effective for preventing falls?
A. Keep the bed in the lowest position with all side rails up
B. Place the call light within the client's reach
C. Encourage the client to wear nonskid socks or footwear
D. Use a bed alarm system
Correct Answer: C
Rationale: While all options are components of a fall prevention plan,
encouraging the use of nonskid footwear directly addresses the
common mechanism of falls—slipping on smooth surfaces. A multi-
faceted approach is best, but this is a fundamental, direct intervention.
Keeping all side rails up can be a restraint and increase fall risk if the
client tries to climb over them. A bed alarm is a monitoring tool, not a
prevention strategy in itself.
Question 5
The nurse is administering medications to a client and notes that the
client has an allergy to penicillin, but a prescription for amoxicillin is
present. What is the nurse's priority action?
A. Administer the amoxicillin as prescribed
B. Contact the healthcare provider to clarify the prescription
C. Ask the client about the type of reaction they had to penicillin
D. Hold the medication and document the allergy in the medical record
Correct Answer: B
Rationale: This is a critical safety issue. Amoxicillin is a penicillin-class
antibiotic and is contraindicated in clients with a true penicillin allergy
, due to cross-reactivity. The nurse's priority is to contact the healthcare
provider immediately to question the prescription, prevent a potential
anaphylactic reaction, and get a new order. The medication must be
held. Documenting the allergy is important but is a secondary action
after addressing the immediate risk.
Question 6
A client is receiving a blood transfusion. Fifteen minutes after the start
of the infusion, the client reports chills and low back pain. What is the
nurse's first action?
A. Slow the infusion rate and reassess in 15 minutes
B. Stop the transfusion and disconnect the IV tubing
C. Stop the transfusion and infuse normal saline with new tubing
D. Administer diphenhydramine (Benadryl) as prescribed
Correct Answer: C
Rationale: These are classic signs of a hemolytic transfusion reaction.
The nurse must immediately stop the transfusion, but also must keep
the IV line open with normal saline and new tubing to maintain venous
access for emergency medications. The blood tubing and bag are then
sent to the blood bank. Slowing the infusion is incorrect and dangerous.
Disconnecting the tubing would lose IV access.
Question 7
Which action by the nursing assistant requires immediate intervention
by the supervising nurse?
A. Placing a client in bed with the side rails up and the bed in the lowest
position
B. Applying a warm compress to a client's IV site without a provider
order
C. Repositioning a client who is on fall precautions every 2 hours
D. Measuring a client's intake and output
