HESI RN Exit Actual Exam 2026/2027 HESI Exit V2 V3 V4
V5 V6 V1 Revised & Updated Complete Questions
Verified Detailed Answers - Pass Guaranteed - A+ Graded
Safe & Effective Care Environment – Management of Care
Q1: The charge nurse is making assignments for the day shift. Which client should be
assigned to the most experienced registered nurse?
A. A client 2 days post-total knee replacement requiring pain medication.
B. A client newly diagnosed with diabetes mellitus needing discharge teaching.
C. A client admitted with a stroke who has aphasia and dysphagia. [CORRECT]
D. A client with chronic obstructive pulmonary disease (COPD) on 2 liters of oxygen.
Correct Answer: C
Rationale: The client with a stroke, aphasia, and dysphagia has complex physiological
and psychosocial needs requiring high-level critical thinking and assessment skills,
making this assignment appropriate for the most experienced nurse.
Q2: A nurse is caring for a client who refuses a blood transfusion due to religious
beliefs. What is the nurse's first action?
A. Administer the blood to save the client's life.
B. Inform the client that the physician will force the transfusion.
C. Respect the client's refusal and document it in the chart. [CORRECT]
D. Ask the family to convince the client.
Correct Answer: C
Rationale: A competent adult has the right to refuse treatment, even life-saving
treatment, based on personal or religious beliefs; the nurse must respect this autonomy
and document the refusal.
Q3: The nurse is caring for four clients. Which client should the nurse assess first?
A. A client with pneumonia who has a temperature of 101°F (38.3°C).
B. A client with a cast on the left leg reporting numbness and tingling of the toes.
[CORRECT]
C. A client 2 days post-appendectomy requesting pain medication.
D. A client with heart failure reporting mild ankle edema.
Correct Answer: B
,Rationale: Numbness and tingling in a limb with a cast can indicate compartment
syndrome or neurovascular compromise, which is a priority over the other stable or
expected findings.
Q4: A client is scheduled for surgery and has not signed the informed consent form.
Which action by the nurse is most appropriate?
A. Have the client sign the form after explaining the procedure.
B. Notify the surgeon that the consent is not signed. [CORRECT]
C. Call the risk management department immediately.
D. Witness the client signing the form after the anesthesiologist explains it.
Correct Answer: B
Rationale: It is the physician's responsibility to obtain informed consent and explain the
procedure, risks, and benefits; the nurse's role is to witness the signature and verify
understanding, but the delay requires notifying the surgeon.
Q5: Which task can the nurse delegate to unlicensed assistive personnel (UAP)?
A. Assessing a client's lung sounds.
B. Inserting a Foley catheter in a female client.
C. Measuring a client's intake and output. [CORRECT]
D. Evaluating the effectiveness of pain medication.
Correct Answer: C
Rationale: Measuring intake and output is a standardized, non-invasive task that falls
within the scope of practice for UAP, whereas assessment and evaluation are nursing
responsibilities.
Q6: A nurse is receiving report on four clients. Which client should be seen as the
priority?
A. A client with a urinary tract infection (UTI) reporting burning on urination.
B. A client with depression who is crying quietly in their room.
C. A client with suicidal ideation who suddenly appears cheerful and is giving away
possessions. [CORRECT]
D. A client with hypertension reporting a mild headache.
Correct Answer: C
Rationale: A sudden lift in mood and giving away possessions are classic signs that a
suicidal client may have made the decision to end their life, requiring immediate
intervention.
Q7: A nurse is caring for a client who is confused and trying to get out of bed. The
physician has an order for bilateral soft wrist restraints. What is the nurse's priority?
A. Apply the restraints immediately to prevent falls.
B. Obtain a verbal order from the physician every 24 hours.
,C. Explore alternative measures before applying restraints. [CORRECT]
D. Tie the restraints to the side rail.
Correct Answer: C
Rationale: Restraint standards require that least restrictive measures be attempted first;
restraints are a last resort and must never be tied to the side rail due to the risk of
strangulation or injury if the rails are lowered.
Q8: A nurse is triaging clients in the emergency department during a disaster. Which
client should be tagged as "expectant" (black tag)?
A. A client with a open femur fracture and stable vital signs.
B. A client with massive head injuries and agonal breathing. [CORRECT]
C. A client with second-degree burns on the arm.
D. A client with chest pain and shortness of breath.
Correct Answer: B
Rationale: In a mass casualty incident with limited resources, clients who have injuries
that are unlikely to survive even with treatment are tagged as "expectant" so that
resources can be focused on those with a chance of survival.
Q9: The nurse manager is reviewing incident reports. Which event requires completion
of an incident report?
A. A client falls out of bed but is uninjured.
B. A client receives their medication 30 minutes late.
C. A nurse accidentally withholds a client's scheduled dose of Lasix. [CORRECT]
D. A client refuses to attend physical therapy.
Correct Answer: C
Rationale: Incident reports are used to document deviations from the standard of care
or unexpected events that could cause harm; withholding a medication is a medication
error that requires reporting.
Q10: A client states, "I want to leave the hospital against medical advice (AMA)." The
nurse should:
A. Tell the client they cannot leave because they are sick.
B. Have the client sign an AMA form. [CORRECT]
C. Call security to detain the client.
D. Notify the hospital attorney immediately.
Correct Answer: B
Rationale: A competent client has the right to leave AMA; the nurse should ensure the
client understands the risks, have them sign an AMA form to protect the facility legally,
and provide discharge instructions.
Q11: Which client is at greatest risk for developing pressure injuries?
, A. A 30-year-old client who is post-operative day 1.
B. An 80-year-old client who is bedbound and incontinent. [CORRECT]
C. A client with diabetes who walks independently.
D. A client with a cast on their arm.
Correct Answer: B
Rationale: Immobility, moisture (incontinence), and advanced age are major risk factors
for pressure injuries due to impaired circulation and prolonged pressure on bony
prominences.
Q12: A nurse is preparing to transfer a client to a rehabilitation facility. What information
is most important to include in the transfer report?
A. The client's favorite food.
B. The client's current medication list and medical history. [CORRECT]
C. The number of visitors the client had.
D. The client's room preference.
Correct Answer: B
Rationale: Continuity of care requires that the receiving facility have accurate medical
data, including medications and history, to ensure safe and effective treatment
continuation.
Q13: A nurse is caring for a client who speaks a different language. The nurse needs to
obtain informed consent for a procedure. What is the best action?
A. Use the client's teenage child to translate.
B. Use a professional medical interpreter. [CORRECT]
C. Draw pictures to explain the procedure.
D. Proceed without consent since it is an emergency.
Correct Answer: B
Rationale: Family members, especially minors, should not be used for medical
translation due to the risk of errors and breaches of confidentiality; a professional
interpreter ensures accurate understanding of complex medical concepts.
Q14: The nurse is performing a focused assessment on a client's cardiovascular
system. Which technique should the nurse use first?
A. Auscultation
B. Inspection [CORRECT]
C. Palpation
D. Percussion
Correct Answer: B
Rationale: The correct sequence for physical assessment is inspection, palpation,
percussion, and auscultation (IPPA), except for the abdomen, where auscultation is
performed before percussion and palpation.
V5 V6 V1 Revised & Updated Complete Questions
Verified Detailed Answers - Pass Guaranteed - A+ Graded
Safe & Effective Care Environment – Management of Care
Q1: The charge nurse is making assignments for the day shift. Which client should be
assigned to the most experienced registered nurse?
A. A client 2 days post-total knee replacement requiring pain medication.
B. A client newly diagnosed with diabetes mellitus needing discharge teaching.
C. A client admitted with a stroke who has aphasia and dysphagia. [CORRECT]
D. A client with chronic obstructive pulmonary disease (COPD) on 2 liters of oxygen.
Correct Answer: C
Rationale: The client with a stroke, aphasia, and dysphagia has complex physiological
and psychosocial needs requiring high-level critical thinking and assessment skills,
making this assignment appropriate for the most experienced nurse.
Q2: A nurse is caring for a client who refuses a blood transfusion due to religious
beliefs. What is the nurse's first action?
A. Administer the blood to save the client's life.
B. Inform the client that the physician will force the transfusion.
C. Respect the client's refusal and document it in the chart. [CORRECT]
D. Ask the family to convince the client.
Correct Answer: C
Rationale: A competent adult has the right to refuse treatment, even life-saving
treatment, based on personal or religious beliefs; the nurse must respect this autonomy
and document the refusal.
Q3: The nurse is caring for four clients. Which client should the nurse assess first?
A. A client with pneumonia who has a temperature of 101°F (38.3°C).
B. A client with a cast on the left leg reporting numbness and tingling of the toes.
[CORRECT]
C. A client 2 days post-appendectomy requesting pain medication.
D. A client with heart failure reporting mild ankle edema.
Correct Answer: B
,Rationale: Numbness and tingling in a limb with a cast can indicate compartment
syndrome or neurovascular compromise, which is a priority over the other stable or
expected findings.
Q4: A client is scheduled for surgery and has not signed the informed consent form.
Which action by the nurse is most appropriate?
A. Have the client sign the form after explaining the procedure.
B. Notify the surgeon that the consent is not signed. [CORRECT]
C. Call the risk management department immediately.
D. Witness the client signing the form after the anesthesiologist explains it.
Correct Answer: B
Rationale: It is the physician's responsibility to obtain informed consent and explain the
procedure, risks, and benefits; the nurse's role is to witness the signature and verify
understanding, but the delay requires notifying the surgeon.
Q5: Which task can the nurse delegate to unlicensed assistive personnel (UAP)?
A. Assessing a client's lung sounds.
B. Inserting a Foley catheter in a female client.
C. Measuring a client's intake and output. [CORRECT]
D. Evaluating the effectiveness of pain medication.
Correct Answer: C
Rationale: Measuring intake and output is a standardized, non-invasive task that falls
within the scope of practice for UAP, whereas assessment and evaluation are nursing
responsibilities.
Q6: A nurse is receiving report on four clients. Which client should be seen as the
priority?
A. A client with a urinary tract infection (UTI) reporting burning on urination.
B. A client with depression who is crying quietly in their room.
C. A client with suicidal ideation who suddenly appears cheerful and is giving away
possessions. [CORRECT]
D. A client with hypertension reporting a mild headache.
Correct Answer: C
Rationale: A sudden lift in mood and giving away possessions are classic signs that a
suicidal client may have made the decision to end their life, requiring immediate
intervention.
Q7: A nurse is caring for a client who is confused and trying to get out of bed. The
physician has an order for bilateral soft wrist restraints. What is the nurse's priority?
A. Apply the restraints immediately to prevent falls.
B. Obtain a verbal order from the physician every 24 hours.
,C. Explore alternative measures before applying restraints. [CORRECT]
D. Tie the restraints to the side rail.
Correct Answer: C
Rationale: Restraint standards require that least restrictive measures be attempted first;
restraints are a last resort and must never be tied to the side rail due to the risk of
strangulation or injury if the rails are lowered.
Q8: A nurse is triaging clients in the emergency department during a disaster. Which
client should be tagged as "expectant" (black tag)?
A. A client with a open femur fracture and stable vital signs.
B. A client with massive head injuries and agonal breathing. [CORRECT]
C. A client with second-degree burns on the arm.
D. A client with chest pain and shortness of breath.
Correct Answer: B
Rationale: In a mass casualty incident with limited resources, clients who have injuries
that are unlikely to survive even with treatment are tagged as "expectant" so that
resources can be focused on those with a chance of survival.
Q9: The nurse manager is reviewing incident reports. Which event requires completion
of an incident report?
A. A client falls out of bed but is uninjured.
B. A client receives their medication 30 minutes late.
C. A nurse accidentally withholds a client's scheduled dose of Lasix. [CORRECT]
D. A client refuses to attend physical therapy.
Correct Answer: C
Rationale: Incident reports are used to document deviations from the standard of care
or unexpected events that could cause harm; withholding a medication is a medication
error that requires reporting.
Q10: A client states, "I want to leave the hospital against medical advice (AMA)." The
nurse should:
A. Tell the client they cannot leave because they are sick.
B. Have the client sign an AMA form. [CORRECT]
C. Call security to detain the client.
D. Notify the hospital attorney immediately.
Correct Answer: B
Rationale: A competent client has the right to leave AMA; the nurse should ensure the
client understands the risks, have them sign an AMA form to protect the facility legally,
and provide discharge instructions.
Q11: Which client is at greatest risk for developing pressure injuries?
, A. A 30-year-old client who is post-operative day 1.
B. An 80-year-old client who is bedbound and incontinent. [CORRECT]
C. A client with diabetes who walks independently.
D. A client with a cast on their arm.
Correct Answer: B
Rationale: Immobility, moisture (incontinence), and advanced age are major risk factors
for pressure injuries due to impaired circulation and prolonged pressure on bony
prominences.
Q12: A nurse is preparing to transfer a client to a rehabilitation facility. What information
is most important to include in the transfer report?
A. The client's favorite food.
B. The client's current medication list and medical history. [CORRECT]
C. The number of visitors the client had.
D. The client's room preference.
Correct Answer: B
Rationale: Continuity of care requires that the receiving facility have accurate medical
data, including medications and history, to ensure safe and effective treatment
continuation.
Q13: A nurse is caring for a client who speaks a different language. The nurse needs to
obtain informed consent for a procedure. What is the best action?
A. Use the client's teenage child to translate.
B. Use a professional medical interpreter. [CORRECT]
C. Draw pictures to explain the procedure.
D. Proceed without consent since it is an emergency.
Correct Answer: B
Rationale: Family members, especially minors, should not be used for medical
translation due to the risk of errors and breaches of confidentiality; a professional
interpreter ensures accurate understanding of complex medical concepts.
Q14: The nurse is performing a focused assessment on a client's cardiovascular
system. Which technique should the nurse use first?
A. Auscultation
B. Inspection [CORRECT]
C. Palpation
D. Percussion
Correct Answer: B
Rationale: The correct sequence for physical assessment is inspection, palpation,
percussion, and auscultation (IPPA), except for the abdomen, where auscultation is
performed before percussion and palpation.
