**HESI RN Exit Exam 2024 NGN: Leadership,
Prioritization, and Delegation**
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**Question 121**
A charge nurse is assigning client care on a medical-surgical unit. Which client should be assigned to a
registered nurse (RN) rather than a licensed practical nurse (LPN)?
A. A client with type 2 diabetes mellitus requiring a fingerstick blood glucose check before meals
B. A client with a hip fracture who needs assistance with bathing and turning
C. A client with a newly placed percutaneous endoscopic gastrostomy (PEG) tube requiring initial feeding
initiation
D. A client with chronic obstructive pulmonary disease (COPD) who needs oxygen saturation monitored
every 4 hours
💫ANSWER✔️✔️: C. A client with a newly placed PEG tube requiring initial feeding initiation
💫RATIONALE✔️✔️: Initial assessment and initiation of a new feeding tube (verifying placement, starting
the feeding, assessing tolerance) requires RN-level assessment and clinical judgment. Stable clients with
routine monitoring and care (blood glucose checks, ADLs, vital signs) can be delegated to LPNs or
nursing assistants.
---
**Question 122**
A nurse receives a telephone order from a healthcare provider for morphine sulfate 4 mg IV push every
2 hours for severe pain. Which action by the nurse is most appropriate?
A. Administer the medication immediately and document the order later
B. Ask the provider to come to the unit to write the order
,C. Read the order back to the provider and document as a telephone order with the provider's name
D. Refuse to accept the order because telephone orders are not permitted
💫ANSWER✔️✔️: C. Read the order back to the provider and document as a telephone order with the
provider's name
💫RATIONALE✔️✔️: Telephone orders are acceptable in emergency or when the provider is off-site. The
nurse must write the order, read it back (verify) to the provider, document "TO" with date, time,
provider name, and nurse signature. The provider must countersign within a facility-defined timeframe
(usually 24-48 hours).
---
**Question 123**
A nurse manager is reviewing infection control practices. Which action by a staff nurse requires
immediate correction?
A. Wearing an N95 respirator when caring for a client with tuberculosis
B. Removing gloves and washing hands before documenting on a client's chart
C. Using alcohol-based hand rub before donning sterile gloves for a urinary catheter insertion
D. Wearing a surgical mask within 3 feet of a client with pertussis
💫ANSWER✔️✔️: C. Using alcohol-based hand rub before donning sterile gloves for a urinary catheter
insertion
💫RATIONALE✔️✔️: For sterile procedures like urinary catheter insertion, the hands must be washed with
antiseptic soap and water (not just alcohol-based rub) because alcohol rubs do not remove all spores
and certain pathogens. Also, sterile gloves are donned after the hand hygiene, but alcohol rub alone is
insufficient before a sterile procedure.
---
**Question 124**
A nurse is caring for a client who is confused and trying to pull out their intravenous (IV) line. The
healthcare provider orders wrist restraints. Which action by the nurse is most appropriate?
, A. Apply the restraints tightly to prevent the client from loosening them
B. Tie the restraints to the side rail of the bed for easy access
C. Remove the restraints every 2 hours to assess skin integrity and range of motion
D. Document that the family requested the restraints to keep the client safe
💫ANSWER✔️✔️: C. Remove the restraints every 2 hours to assess skin integrity and range of motion
💫RATIONALE✔️✔️: Restraint standards require release every 2 hours (or per facility policy) for skin
assessment, hydration, toileting, and range of motion. Restraints must be tied to the bed frame (not side
rails, which move), with a quick-release knot. Orders require renewal every 24 hours.
---
**Question 125**
A nurse is preparing to give change-of-shift report on four clients. Which client should the nurse report
first?
A. A client with pneumonia who has an oxygen saturation of 92% on 2 L/min oxygen
B. A client with congestive heart failure who has gained 2 pounds since yesterday
C. A client with a hip fracture who is requesting pain medication for pain rated 5/10
D. A client with a stroke who has new-onset difficulty swallowing and a weak cough
💫ANSWER✔️✔️: D. A client with a stroke who has new-onset difficulty swallowing and a weak cough
💫RATIONALE✔️✔️: New dysphagia and weak cough indicate increased risk of aspiration pneumonia and
airway compromise. This is an acute change requiring immediate assessment and intervention (NPO
status, swallow evaluation). This is the highest priority using the "acute change" and "airway" criteria.
---
**Question 126**
A nurse on a cardiac unit receives a handoff report. Which client should the nurse see first?
A. A client with unstable angina who received nitroglycerin 30 minutes ago and reports pain decreased
from 7/10 to 2/10
Prioritization, and Delegation**
---
**Question 121**
A charge nurse is assigning client care on a medical-surgical unit. Which client should be assigned to a
registered nurse (RN) rather than a licensed practical nurse (LPN)?
A. A client with type 2 diabetes mellitus requiring a fingerstick blood glucose check before meals
B. A client with a hip fracture who needs assistance with bathing and turning
C. A client with a newly placed percutaneous endoscopic gastrostomy (PEG) tube requiring initial feeding
initiation
D. A client with chronic obstructive pulmonary disease (COPD) who needs oxygen saturation monitored
every 4 hours
💫ANSWER✔️✔️: C. A client with a newly placed PEG tube requiring initial feeding initiation
💫RATIONALE✔️✔️: Initial assessment and initiation of a new feeding tube (verifying placement, starting
the feeding, assessing tolerance) requires RN-level assessment and clinical judgment. Stable clients with
routine monitoring and care (blood glucose checks, ADLs, vital signs) can be delegated to LPNs or
nursing assistants.
---
**Question 122**
A nurse receives a telephone order from a healthcare provider for morphine sulfate 4 mg IV push every
2 hours for severe pain. Which action by the nurse is most appropriate?
A. Administer the medication immediately and document the order later
B. Ask the provider to come to the unit to write the order
,C. Read the order back to the provider and document as a telephone order with the provider's name
D. Refuse to accept the order because telephone orders are not permitted
💫ANSWER✔️✔️: C. Read the order back to the provider and document as a telephone order with the
provider's name
💫RATIONALE✔️✔️: Telephone orders are acceptable in emergency or when the provider is off-site. The
nurse must write the order, read it back (verify) to the provider, document "TO" with date, time,
provider name, and nurse signature. The provider must countersign within a facility-defined timeframe
(usually 24-48 hours).
---
**Question 123**
A nurse manager is reviewing infection control practices. Which action by a staff nurse requires
immediate correction?
A. Wearing an N95 respirator when caring for a client with tuberculosis
B. Removing gloves and washing hands before documenting on a client's chart
C. Using alcohol-based hand rub before donning sterile gloves for a urinary catheter insertion
D. Wearing a surgical mask within 3 feet of a client with pertussis
💫ANSWER✔️✔️: C. Using alcohol-based hand rub before donning sterile gloves for a urinary catheter
insertion
💫RATIONALE✔️✔️: For sterile procedures like urinary catheter insertion, the hands must be washed with
antiseptic soap and water (not just alcohol-based rub) because alcohol rubs do not remove all spores
and certain pathogens. Also, sterile gloves are donned after the hand hygiene, but alcohol rub alone is
insufficient before a sterile procedure.
---
**Question 124**
A nurse is caring for a client who is confused and trying to pull out their intravenous (IV) line. The
healthcare provider orders wrist restraints. Which action by the nurse is most appropriate?
, A. Apply the restraints tightly to prevent the client from loosening them
B. Tie the restraints to the side rail of the bed for easy access
C. Remove the restraints every 2 hours to assess skin integrity and range of motion
D. Document that the family requested the restraints to keep the client safe
💫ANSWER✔️✔️: C. Remove the restraints every 2 hours to assess skin integrity and range of motion
💫RATIONALE✔️✔️: Restraint standards require release every 2 hours (or per facility policy) for skin
assessment, hydration, toileting, and range of motion. Restraints must be tied to the bed frame (not side
rails, which move), with a quick-release knot. Orders require renewal every 24 hours.
---
**Question 125**
A nurse is preparing to give change-of-shift report on four clients. Which client should the nurse report
first?
A. A client with pneumonia who has an oxygen saturation of 92% on 2 L/min oxygen
B. A client with congestive heart failure who has gained 2 pounds since yesterday
C. A client with a hip fracture who is requesting pain medication for pain rated 5/10
D. A client with a stroke who has new-onset difficulty swallowing and a weak cough
💫ANSWER✔️✔️: D. A client with a stroke who has new-onset difficulty swallowing and a weak cough
💫RATIONALE✔️✔️: New dysphagia and weak cough indicate increased risk of aspiration pneumonia and
airway compromise. This is an acute change requiring immediate assessment and intervention (NPO
status, swallow evaluation). This is the highest priority using the "acute change" and "airway" criteria.
---
**Question 126**
A nurse on a cardiac unit receives a handoff report. Which client should the nurse see first?
A. A client with unstable angina who received nitroglycerin 30 minutes ago and reports pain decreased
from 7/10 to 2/10
