HESI Exit PN | HESI Exit PN Exam Version 6
Comprehensive Review | Questions with Correct
Answers and Expert Explanation for Each Question
| Nursing Exit Assessment
1. A practical nurse (PN) is assigned to care for four clients. Which client should the PN
see first?
A. A client with pneumonia who has a new onset of confusion and restlessness.
B. A client who underwent an appendectomy 24 hours ago and reports pain as 4 on
a scale of 10.
C. A client with a history of heart failure who has 2+ pitting edema in the lower
extremities.
D. A client with diabetes mellitus whose morning blood glucose level is 140 mg/dL.
Correct Answer: A
Expert Explanation: New onset confusion and restlessness in a pneumonia client
are early signs of hypoxia. The nurse must prioritize respiratory status using the
ABC (Airway, Breathing, Circulation) framework. The other clients exhibit expected
findings or stable conditions that do not require immediate intervention. Edema and
moderate post-operative pain are typical for those specific clinical situations.
Addressing the potentially hypoxic client first prevents further physiological
decline.
,2. The practical nurse (PN) is planning to delegate tasks to an Unlicensed Assistive
Personnel (UAP). Which task is most appropriate for the PN to delegate?
A. Providing discharge instructions to a client going home with a cast.
B. Monitoring a client’s response to a new antihypertensive medication.
C. Performing an initial skin assessment on a newly admitted client.
D. Assisting a stable client with a walker to the bathroom.
Correct Answer: D
Expert Explanation: The UAP is trained to assist stable clients with activities of
daily living, such as ambulation. Assessment, evaluation of medication response, and
patient teaching are responsibilities of the licensed nurse and cannot be delegated.
Delegation must follow the five rights of delegation to ensure patient safety. The PN
remains accountable for the tasks delegated to the UAP. Choosing the correct task
prevents the UAP from working outside their scope of practice.
3. A client is scheduled for an elective surgery. Which action should the practical nurse
(PN) take to fulfill the legal responsibility regarding informed consent?
A. Explaining the risks and benefits of the surgical procedure to the client.
B. Determining the client’s competency to undergo the procedure.
C. Witnessing the client’s signature on the consent form.
,D. Obtaining the signature from a family member if the client is hesitant.
Correct Answer: C
Expert Explanation: The nurse’s legal role in informed consent is to witness the
client signing the form voluntarily. It is the surgeon’s responsibility to explain the
procedure, risks, and benefits to the client. The nurse must ensure the client is
competent and has no further questions for the physician. If the client does not
understand the procedure, the nurse must notify the surgeon before the client signs.
Informed consent is a fundamental ethical and legal requirement in healthcare.
4. The practical nurse (PN) is caring for a client with a prescription for a clear liquid
diet. Which food item should the PN remove from the client’s meal tray?
A. Apple juice.
B. Chicken broth.
C. Vanilla pudding.
D. Lemon gelatin.
Correct Answer: C
Expert Explanation: Vanilla pudding is considered a full liquid, not a clear liquid,
because it contains dairy products. Clear liquids are items that are transparent at
room temperature and leave minimal residue in the GI tract. Apple juice, broth, and
gelatin are all appropriate choices for a clear liquid diet. Providing the wrong diet
, can lead to complications, especially for post-operative or pre-diagnostic clients.
The PN must verify diet orders before delivering trays to ensure client safety.
5. Which client situation requires the practical nurse (PN) to complete an incident
(occurrence) report?
A. A client refuses to take a scheduled dose of an oral antibiotic.
B. A client’s blood pressure is slightly elevated after physical therapy.
C. A visitor slips in the hallway but states they are not injured.
D. A client asks to be discharged against medical advice.
Correct Answer: C
Expert Explanation: An incident report must be completed for any unusual event
that could result in harm, including visitor injuries. Even if the visitor claims they
are uninjured, the event must be documented for legal and risk management
purposes. Refusal of medication is documented in the medical record but does not
usually require an incident report unless it leads to a critical error. Routine
physiological changes like BP elevation after exercise are expected. Incident reports
are internal documents used for quality improvement and are not part of the client’s
permanent record.
Comprehensive Review | Questions with Correct
Answers and Expert Explanation for Each Question
| Nursing Exit Assessment
1. A practical nurse (PN) is assigned to care for four clients. Which client should the PN
see first?
A. A client with pneumonia who has a new onset of confusion and restlessness.
B. A client who underwent an appendectomy 24 hours ago and reports pain as 4 on
a scale of 10.
C. A client with a history of heart failure who has 2+ pitting edema in the lower
extremities.
D. A client with diabetes mellitus whose morning blood glucose level is 140 mg/dL.
Correct Answer: A
Expert Explanation: New onset confusion and restlessness in a pneumonia client
are early signs of hypoxia. The nurse must prioritize respiratory status using the
ABC (Airway, Breathing, Circulation) framework. The other clients exhibit expected
findings or stable conditions that do not require immediate intervention. Edema and
moderate post-operative pain are typical for those specific clinical situations.
Addressing the potentially hypoxic client first prevents further physiological
decline.
,2. The practical nurse (PN) is planning to delegate tasks to an Unlicensed Assistive
Personnel (UAP). Which task is most appropriate for the PN to delegate?
A. Providing discharge instructions to a client going home with a cast.
B. Monitoring a client’s response to a new antihypertensive medication.
C. Performing an initial skin assessment on a newly admitted client.
D. Assisting a stable client with a walker to the bathroom.
Correct Answer: D
Expert Explanation: The UAP is trained to assist stable clients with activities of
daily living, such as ambulation. Assessment, evaluation of medication response, and
patient teaching are responsibilities of the licensed nurse and cannot be delegated.
Delegation must follow the five rights of delegation to ensure patient safety. The PN
remains accountable for the tasks delegated to the UAP. Choosing the correct task
prevents the UAP from working outside their scope of practice.
3. A client is scheduled for an elective surgery. Which action should the practical nurse
(PN) take to fulfill the legal responsibility regarding informed consent?
A. Explaining the risks and benefits of the surgical procedure to the client.
B. Determining the client’s competency to undergo the procedure.
C. Witnessing the client’s signature on the consent form.
,D. Obtaining the signature from a family member if the client is hesitant.
Correct Answer: C
Expert Explanation: The nurse’s legal role in informed consent is to witness the
client signing the form voluntarily. It is the surgeon’s responsibility to explain the
procedure, risks, and benefits to the client. The nurse must ensure the client is
competent and has no further questions for the physician. If the client does not
understand the procedure, the nurse must notify the surgeon before the client signs.
Informed consent is a fundamental ethical and legal requirement in healthcare.
4. The practical nurse (PN) is caring for a client with a prescription for a clear liquid
diet. Which food item should the PN remove from the client’s meal tray?
A. Apple juice.
B. Chicken broth.
C. Vanilla pudding.
D. Lemon gelatin.
Correct Answer: C
Expert Explanation: Vanilla pudding is considered a full liquid, not a clear liquid,
because it contains dairy products. Clear liquids are items that are transparent at
room temperature and leave minimal residue in the GI tract. Apple juice, broth, and
gelatin are all appropriate choices for a clear liquid diet. Providing the wrong diet
, can lead to complications, especially for post-operative or pre-diagnostic clients.
The PN must verify diet orders before delivering trays to ensure client safety.
5. Which client situation requires the practical nurse (PN) to complete an incident
(occurrence) report?
A. A client refuses to take a scheduled dose of an oral antibiotic.
B. A client’s blood pressure is slightly elevated after physical therapy.
C. A visitor slips in the hallway but states they are not injured.
D. A client asks to be discharged against medical advice.
Correct Answer: C
Expert Explanation: An incident report must be completed for any unusual event
that could result in harm, including visitor injuries. Even if the visitor claims they
are uninjured, the event must be documented for legal and risk management
purposes. Refusal of medication is documented in the medical record but does not
usually require an incident report unless it leads to a critical error. Routine
physiological changes like BP elevation after exercise are expected. Incident reports
are internal documents used for quality improvement and are not part of the client’s
permanent record.
