HESI RN Exit Exam | NGN Nursing UP-TO-DATE 2026
EXAM QUESTIONS AND 100% ACCURATE SOLUTIONS |
Question And VERIFIED ANSWERS - INSTANT PDF
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SECTION 1: SAFE & EFFECTIVE CARE ENVIRONMENT –
DELEGATION & MANAGEMENT
Question 1
A nurse is preparing to delegate tasks to an unlicensed assistive personnel (UAP). Which
task is appropriate for the nurse to delegate?
A) Assessing a client's pain level
B) Administering oral medications
C) Ambulating a stable client
D) Evaluating the effectiveness of pain medication
Correct Answer: C) Ambulating a stable client
Rationale: Delegation follows the "Five Rights": right task, right circumstance, right person,
right direction/communication, and right supervision. UAP can ambulate stable clients,
assist with activities of daily living, and obtain vital signs on stable clients. Assessment,
medication administration, and evaluation are responsibilities of the licensed nurse .
Question 2
A nurse receives a telephone order from a provider for a client's pain medication. What
is the nurse's priority action?
,A) Implement the order immediately
B) Write the order in the chart and sign "TO"
C) Read the order back to the provider for verification
D) Ask another nurse to listen to the order
Correct Answer: C) Read the order back to the provider for verification
Rationale: The "read back" process is a critical safety measure that ensures accurate
communication of verbal and telephone orders. This reduces medication errors and is
required by The Joint Commission .
Question 3
A nurse is caring for a client with a new prescription for wrist restraints. Which action is
most important?
A) Document the reason for restraint use
B) Tie the restraints to the bed frame (not side rail)
C) Remove restraints every 4 hours for range of motion
D) Obtain a PRN order for restraints
Correct Answer: B) Tie the restraints to the bed frame (not side rail)
Rationale: Restraints must be tied to the bed frame, not the side rail, to prevent injury if
the side rail is lowered. Restraints require a written order, must be removed every 2 hours
for ROM, and should never be PRN .
Question 4
A nurse is completing an incident report after a client fall. Which action is correct
regarding incident report documentation?
A) Include the incident report in the client's medical record
B) Document "incident report filed" in the client's chart
C) Make a copy of the incident report for the client
D) Describe the incident in detail in the progress notes
Correct Answer: B) Document "incident report filed" in the client's chart
,Rationale: The incident report is a confidential risk management document and should
NOT be placed in the medical record. The nurse should document factual information
about the fall in the progress notes. The phrase "incident report filed" is acceptable as
minimal documentation of the report's existence .
Question 5
A nurse is caring for a client who is receiving a blood transfusion. The client reports
chills and back pain. What is the nurse's priority action?
A) Slow the infusion rate
B) Stop the transfusion
C) Notify the provider
D) Administer acetaminophen
Correct Answer: B) Stop the transfusion
Rationale: Suspect a hemolytic transfusion reaction. Stop the transfusion immediately (first
action), keep the IV line open with normal saline, notify the provider, and send the blood
bag and tubing to the lab .
Question 6
A nurse is caring for a client who is receiving IV vancomycin. The client reports itching
and a red rash on the neck and chest. What is the nurse's priority action?
A) Administer diphenhydramine
B) Stop the infusion
C) Slow the infusion rate
D) Notify the provider
Correct Answer: B) Stop the infusion
Rationale: Red man syndrome is a histamine-release reaction to rapid vancomycin
infusion. The nurse should stop the infusion immediately, notify the provider, and
administer antihistamines as ordered. Future doses should be infused over ≥60 minutes .
, Question 7
A nurse is caring for a client with a new diagnosis of Clostridioides difficile. Which
infection control precautions should the nurse implement?
A) Standard precautions
B) Contact precautions with soap and water for hand hygiene
C) Droplet precautions
D) Airborne precautions
Correct Answer: B) Contact precautions with soap and water
Rationale: C. diff spores are not killed by alcohol-based hand sanitizers. Contact
precautions require gown and gloves, and hand hygiene must be performed with soap and
water (friction and rinsing removes spores) .
Question 8
A nurse is preparing to administer a blood transfusion. Which IV solution is compatible
with blood products?
A) Lactated Ringer's solution
B) 5% Dextrose in water
C) 0.9% Normal saline
D) 0.45% Normal saline
Correct Answer: C) 0.9% Normal saline
Rationale: Only 0.9% normal saline is compatible with blood products. Dextrose solutions
can cause hemolysis, and lactated Ringer's contains calcium that can cause clotting in the
tubing .
Question 9
A nurse is delegating vital signs to a UAP for a client who is postoperative day 1. The
UAP reports a blood pressure of 80/50. What should the nurse do first?
EXAM QUESTIONS AND 100% ACCURATE SOLUTIONS |
Question And VERIFIED ANSWERS - INSTANT PDF
DOWNLOAD Latest PDF Update)
SECTION 1: SAFE & EFFECTIVE CARE ENVIRONMENT –
DELEGATION & MANAGEMENT
Question 1
A nurse is preparing to delegate tasks to an unlicensed assistive personnel (UAP). Which
task is appropriate for the nurse to delegate?
A) Assessing a client's pain level
B) Administering oral medications
C) Ambulating a stable client
D) Evaluating the effectiveness of pain medication
Correct Answer: C) Ambulating a stable client
Rationale: Delegation follows the "Five Rights": right task, right circumstance, right person,
right direction/communication, and right supervision. UAP can ambulate stable clients,
assist with activities of daily living, and obtain vital signs on stable clients. Assessment,
medication administration, and evaluation are responsibilities of the licensed nurse .
Question 2
A nurse receives a telephone order from a provider for a client's pain medication. What
is the nurse's priority action?
,A) Implement the order immediately
B) Write the order in the chart and sign "TO"
C) Read the order back to the provider for verification
D) Ask another nurse to listen to the order
Correct Answer: C) Read the order back to the provider for verification
Rationale: The "read back" process is a critical safety measure that ensures accurate
communication of verbal and telephone orders. This reduces medication errors and is
required by The Joint Commission .
Question 3
A nurse is caring for a client with a new prescription for wrist restraints. Which action is
most important?
A) Document the reason for restraint use
B) Tie the restraints to the bed frame (not side rail)
C) Remove restraints every 4 hours for range of motion
D) Obtain a PRN order for restraints
Correct Answer: B) Tie the restraints to the bed frame (not side rail)
Rationale: Restraints must be tied to the bed frame, not the side rail, to prevent injury if
the side rail is lowered. Restraints require a written order, must be removed every 2 hours
for ROM, and should never be PRN .
Question 4
A nurse is completing an incident report after a client fall. Which action is correct
regarding incident report documentation?
A) Include the incident report in the client's medical record
B) Document "incident report filed" in the client's chart
C) Make a copy of the incident report for the client
D) Describe the incident in detail in the progress notes
Correct Answer: B) Document "incident report filed" in the client's chart
,Rationale: The incident report is a confidential risk management document and should
NOT be placed in the medical record. The nurse should document factual information
about the fall in the progress notes. The phrase "incident report filed" is acceptable as
minimal documentation of the report's existence .
Question 5
A nurse is caring for a client who is receiving a blood transfusion. The client reports
chills and back pain. What is the nurse's priority action?
A) Slow the infusion rate
B) Stop the transfusion
C) Notify the provider
D) Administer acetaminophen
Correct Answer: B) Stop the transfusion
Rationale: Suspect a hemolytic transfusion reaction. Stop the transfusion immediately (first
action), keep the IV line open with normal saline, notify the provider, and send the blood
bag and tubing to the lab .
Question 6
A nurse is caring for a client who is receiving IV vancomycin. The client reports itching
and a red rash on the neck and chest. What is the nurse's priority action?
A) Administer diphenhydramine
B) Stop the infusion
C) Slow the infusion rate
D) Notify the provider
Correct Answer: B) Stop the infusion
Rationale: Red man syndrome is a histamine-release reaction to rapid vancomycin
infusion. The nurse should stop the infusion immediately, notify the provider, and
administer antihistamines as ordered. Future doses should be infused over ≥60 minutes .
, Question 7
A nurse is caring for a client with a new diagnosis of Clostridioides difficile. Which
infection control precautions should the nurse implement?
A) Standard precautions
B) Contact precautions with soap and water for hand hygiene
C) Droplet precautions
D) Airborne precautions
Correct Answer: B) Contact precautions with soap and water
Rationale: C. diff spores are not killed by alcohol-based hand sanitizers. Contact
precautions require gown and gloves, and hand hygiene must be performed with soap and
water (friction and rinsing removes spores) .
Question 8
A nurse is preparing to administer a blood transfusion. Which IV solution is compatible
with blood products?
A) Lactated Ringer's solution
B) 5% Dextrose in water
C) 0.9% Normal saline
D) 0.45% Normal saline
Correct Answer: C) 0.9% Normal saline
Rationale: Only 0.9% normal saline is compatible with blood products. Dextrose solutions
can cause hemolysis, and lactated Ringer's contains calcium that can cause clotting in the
tubing .
Question 9
A nurse is delegating vital signs to a UAP for a client who is postoperative day 1. The
UAP reports a blood pressure of 80/50. What should the nurse do first?
