, HESI Exit V4
1. The nurse receives shift report on 4 clients. Which client should be assessed FIRST?
A Client with heart failure, crackles in mid-lung fields
B Client with diabetes mellitus, blood glucose 180 mg/dL
C Client with tracheostomy, oxygen saturation 86%
D Client with appendicitis, temperature 100.4°F (38°C)
Correct Answer: C
Rationale: An oxygen saturation of 86% indicates severe hypoxemia, making airway and
breathing the priority. Crackles in heart failure (A) are expected findings. A blood glucose of 180
mg/dL (B) is elevated but not immediately critical. A low-grade fever with appendicitis (D) is
expected .
2. An LPN is assigned to care for a stable client with a colostomy. Which task should the RN
delegate to the LPN?
A Teaching the client how to irrigate the colostomy
B Performing colostomy bag change
C Assessing the stoma for ischemia
D Developing the colostomy care plan
Correct Answer: B
Rationale: LPNs can perform stable, standard procedures such as colostomy bag changes.
Teaching (A), assessment (C), and care planning (D) require RN scope of practice .
3. A client refuses a blood transfusion due to religious beliefs (Jehovah's Witness). What is the
nurse's best response?
A "You will die without this transfusion."
B "Let me call your family to convince you."
C "I respect your decision. I will notify your provider."
D "We will give it anyway if it's an emergency."
Correct Answer: C
,Rationale: Client autonomy must be respected. Option C is ethical, legal, and therapeutic.
Forcing a transfusion (D) constitutes battery. Threatening the client (A) or involving family
against the client's wishes (B) are inappropriate .
4. Which client can be assigned to an RN who is pregnant?
A Client receiving oral acyclovir for herpes zoster
B Client with stable angina
C Client with active cytomegalovirus (CMV)
D Client receiving IV ribavirin
Correct Answer: B
Rationale: A client with stable angina poses no infectious risk to a pregnant RN. Acyclovir (A) is
category B but the risk is minimal. Active CMV (C) and IV ribavirin (D) are category X and should
be avoided by pregnant staff .
5. A client with terminal cancer requests no further chemotherapy. The family insists on
continued treatment. What should the nurse do?
A Support the client's decision and notify the provider
B Follow the family's wishes to avoid conflict
C Give chemotherapy as prescribed
D Request an ethics committee meeting before acting
Correct Answer: A
Rationale: Client autonomy overrides family wishes. Informed refusal must be respected. The
provider should be notified of the client's decision .
6. Which task can the nurse delegate to an unlicensed assistive personnel (UAP)?
A Assess a client's post-operative incision
B Teach a client how to use an incentive spirometer
C Obtain a daily weight on a client with heart failure
D Evaluate the effectiveness of pain medication
Correct Answer: C
, Rationale: UAPs can obtain stable, routine measurements such as daily weights. Assessment
(A), teaching (B), and evaluation (D) are RN duties .
7. A client signs a consent form for surgery. The nurse witnesses the signature but notes the
client seems sedated. What should the nurse do?
A Let the client proceed to surgery
B Notify the surgeon and document sedation
C Ask the family to cosign
D Cancel the surgery immediately
Correct Answer: B
Rationale: Consent must be informed and voluntary. Sedated clients cannot legally consent. The
surgeon must re-consent when the client is alert .
8. The charge nurse is making assignments. Which client is most appropriate for a new graduate
RN?
A Client with unstable ventricular tachycardia
B Client with pneumonia requiring IV antibiotics
C Client on a continuous heparin drip with aPTT 110
D Client post-cardiac arrest on vasopressors
Correct Answer: B
Rationale: A stable client with pneumonia requiring routine IV antibiotics is appropriate for a
new graduate. Unstable rhythms (A), high-risk infusions (C), and critical care (D) require
experienced RNs .
9. A nurse is floated to an unfamiliar unit. What is the best action?
A Refuse the assignment
B Request orientation to the unit and clarify tasks
C Care only for stable clients
D Ask another nurse to cosign all care
Correct Answer: B
1. The nurse receives shift report on 4 clients. Which client should be assessed FIRST?
A Client with heart failure, crackles in mid-lung fields
B Client with diabetes mellitus, blood glucose 180 mg/dL
C Client with tracheostomy, oxygen saturation 86%
D Client with appendicitis, temperature 100.4°F (38°C)
Correct Answer: C
Rationale: An oxygen saturation of 86% indicates severe hypoxemia, making airway and
breathing the priority. Crackles in heart failure (A) are expected findings. A blood glucose of 180
mg/dL (B) is elevated but not immediately critical. A low-grade fever with appendicitis (D) is
expected .
2. An LPN is assigned to care for a stable client with a colostomy. Which task should the RN
delegate to the LPN?
A Teaching the client how to irrigate the colostomy
B Performing colostomy bag change
C Assessing the stoma for ischemia
D Developing the colostomy care plan
Correct Answer: B
Rationale: LPNs can perform stable, standard procedures such as colostomy bag changes.
Teaching (A), assessment (C), and care planning (D) require RN scope of practice .
3. A client refuses a blood transfusion due to religious beliefs (Jehovah's Witness). What is the
nurse's best response?
A "You will die without this transfusion."
B "Let me call your family to convince you."
C "I respect your decision. I will notify your provider."
D "We will give it anyway if it's an emergency."
Correct Answer: C
,Rationale: Client autonomy must be respected. Option C is ethical, legal, and therapeutic.
Forcing a transfusion (D) constitutes battery. Threatening the client (A) or involving family
against the client's wishes (B) are inappropriate .
4. Which client can be assigned to an RN who is pregnant?
A Client receiving oral acyclovir for herpes zoster
B Client with stable angina
C Client with active cytomegalovirus (CMV)
D Client receiving IV ribavirin
Correct Answer: B
Rationale: A client with stable angina poses no infectious risk to a pregnant RN. Acyclovir (A) is
category B but the risk is minimal. Active CMV (C) and IV ribavirin (D) are category X and should
be avoided by pregnant staff .
5. A client with terminal cancer requests no further chemotherapy. The family insists on
continued treatment. What should the nurse do?
A Support the client's decision and notify the provider
B Follow the family's wishes to avoid conflict
C Give chemotherapy as prescribed
D Request an ethics committee meeting before acting
Correct Answer: A
Rationale: Client autonomy overrides family wishes. Informed refusal must be respected. The
provider should be notified of the client's decision .
6. Which task can the nurse delegate to an unlicensed assistive personnel (UAP)?
A Assess a client's post-operative incision
B Teach a client how to use an incentive spirometer
C Obtain a daily weight on a client with heart failure
D Evaluate the effectiveness of pain medication
Correct Answer: C
, Rationale: UAPs can obtain stable, routine measurements such as daily weights. Assessment
(A), teaching (B), and evaluation (D) are RN duties .
7. A client signs a consent form for surgery. The nurse witnesses the signature but notes the
client seems sedated. What should the nurse do?
A Let the client proceed to surgery
B Notify the surgeon and document sedation
C Ask the family to cosign
D Cancel the surgery immediately
Correct Answer: B
Rationale: Consent must be informed and voluntary. Sedated clients cannot legally consent. The
surgeon must re-consent when the client is alert .
8. The charge nurse is making assignments. Which client is most appropriate for a new graduate
RN?
A Client with unstable ventricular tachycardia
B Client with pneumonia requiring IV antibiotics
C Client on a continuous heparin drip with aPTT 110
D Client post-cardiac arrest on vasopressors
Correct Answer: B
Rationale: A stable client with pneumonia requiring routine IV antibiotics is appropriate for a
new graduate. Unstable rhythms (A), high-risk infusions (C), and critical care (D) require
experienced RNs .
9. A nurse is floated to an unfamiliar unit. What is the best action?
A Refuse the assignment
B Request orientation to the unit and clarify tasks
C Care only for stable clients
D Ask another nurse to cosign all care
Correct Answer: B
