HESI LEADERSHIP ACTUAL EXAM
2026/2027 Edition
80 Questions and Answers with Rationales
Verified | Aligned with Elsevier HESI Leadership & Management Curriculum
Next Generation NCLEX (NGN) Standards Compliant
Key Features
Delegation, prioritization, and assignment of nursing tasks
Quality improvement, incident reporting, and change management
Legal, ethical, and professional responsibilities of the nurse
Conflict resolution, communication, and interdisciplinary collaboration
Resource management, staffing, and healthcare delivery systems
Updates for 2026
Updated ANA Standards: The 2026 American Nurses Association standards for nursing professional
development and shared governance have been integrated, reflecting the latest expectations for nurse autonomy,
evidence-based practice, and collaborative decision-making within healthcare organizations.
Revised 2026 National Patient Safety Goals (NPSGs): The Joint Commission's updated NPSGs now
place heightened emphasis on clinical escalation protocols, rapid response activation, and early recognition of
patient deterioration, requiring nurses to demonstrate competency in these critical safety domains.
New Elsevier Frameworks: Elsevier has introduced updated frameworks for managing nurse burnout,
promoting resilience, and preventing workplace violence, recognizing the impact of workforce well-being on
patient safety and care quality outcomes.
Abstract
This comprehensive document presents an 80-question actual exam designed to evaluate competency across the
core domains of nursing leadership and management as defined by the 2026/2027 Elsevier HESI Leadership
and Management curriculum and aligned with Next Generation NCLEX (NGN) standards. The examination
encompasses five critical domains: Delegation and Prioritization, Quality Improvement and Patient Safety, Legal
Ethical and Professional Issues, Communication and Conflict Management, and Resource Management and
Healthcare Systems. Each question is accompanied by a detailed rationale explaining the correct answer and an
analysis of why the distractors are incorrect, supported by references to current nursing leadership literature,
ANA standards, and evidence-based clinical guidelines. The content emphasizes effective delegation practices,
quality and safety initiatives, ethical decision-making frameworks, and the nurse manager's role in optimizing
patient care outcomes and team dynamics. This resource is designed to prepare nursing candidates for the HESI
Leadership actual exam while reinforcing the clinical judgment and professional competencies essential for
contemporary nursing leadership practice.
Keywords
HESI Leadership, Nursing Management, Delegation, Prioritization, Quality Improvement, Change Management,
Legal/Ethical Issues, Conflict Resolution, NGN
,Content Area Overview
Content Area Questions Key Topics Weight
Delegation & 1-16 Five rights of delegation, 20%
Prioritization scope of practice, ABC
prioritization, task
assignment, supervision
Quality Improvement & 17-32 PDSA cycle, incident 20%
Patient Safety reporting, just culture,
root cause analysis,
NPSGs, clinical
escalation
Legal, Ethical & 33-48 Autonomy, HIPAA, 20%
Professional Issues informed consent,
advance directives,
mandatory reporting,
malpractice
Communication & 49-64 SBAR, CUS, conflict 20%
Conflict Management resolution strategies,
therapeutic
communication, handoff
communication
Resource Management & 65-80 Budgeting, staffing 20%
Healthcare Systems models, shared
governance, value-based
care, benchmarking,
Magnet designation
Examination Questions
Domain: Delegation & Prioritization
1. A registered nurse (RN) on a medical-surgical unit is caring for five patients. Which patient
should the RN assess first?
A. A patient requesting pain medication for a chronic condition
B. A patient with a new onset of shortness of breath and decreased oxygen saturation
C. A patient who is scheduled for discharge later today
D. A patient who needs assistance with ambulation after surgery
Correct Answer: B
Rationale: Using the ABC (Airway, Breathing, Circulation) framework and Maslow's hierarchy of needs, a
patient with new-onset shortness of breath and decreased oxygen saturation represents the highest priority.
This patient may be experiencing a life-threatening respiratory compromise requiring immediate assessment
and intervention to ensure adequate oxygenation and ventilation.
Why Wrong: A is a chronic need that, while important, is not life-threatening. C is a routine discharge
process that can be addressed after acute needs. D is a standard postoperative mobility need that is not
emergent.
Reference: Marquis, B.L. & Huston, C.J. (2026). Leadership Roles and Management Functions in Nursing
(12th ed.), Ch. 12; ANA Standards of Practice, Standard 5.
2. The charge nurse is delegating tasks to a licensed practical nurse (LPN) and an unlicensed
assistive personnel (UAP). Which task is most appropriate to delegate to the LPN?
A. Ambulating a stable postoperative patient
B. Administering oral medications to a stable patient
, C. Developing a nursing care plan for a newly admitted patient
D. Providing initial health teaching to a patient with a new diabetes diagnosis
Correct Answer: B
Rationale: LPNs are licensed to administer oral medications to stable patients under the supervision of an
RN. This falls within their scope of practice as defined by state nurse practice acts. The RN retains
accountability for the overall plan of care and must ensure the LPN is competent to perform this specific task,
but medication administration to stable patients is a delegated nursing function the LPN is educationally
prepared to perform.
Why Wrong: A is within UAP scope and does not require LPN licensure. C requires RN-level assessment,
critical thinking, and nursing diagnosis, which is outside the LPN scope. D involves initial teaching requiring
comprehensive RN assessment and evaluation of learning readiness.
Reference: ANA Principles for Delegation (2026); NCSBN Decision-Making Framework; Marquis & Huston,
Ch. 14.
3. A nurse manager receives multiple patient complaints about delayed responses to call lights.
Which action should the nurse manager take first?
A. Implement a new staffing model immediately
B. Gather data on call light response times and patterns
C. Discipline the nursing staff for delayed responses
D. Reassign staff to different patient assignments
Correct Answer: B
Rationale: The nurse manager must first gather objective data to understand the scope, timing, and
contributing factors of the problem before implementing solutions. This evidence-based approach aligns with
quality improvement methodologies such as Plan-Do-Study-Act (PDSA), ensuring that interventions address
root causes rather than symptoms. Premature action without data analysis may worsen the problem or create
new issues.
Why Wrong: A is premature without data analysis; a new staffing model may not address the actual cause.
C is punitive and does not address systemic issues; it may also reduce morale. D is a temporary fix that does
not address underlying workflow or staffing problems.
Reference: Marquis & Huston (2026), Ch. 20; ANA Leadership Standards; IHI Quality Improvement
Framework.
4. An RN is assigned to care for four patients. Which task can be safely delegated to UAP?
A. Teaching a patient about a newly prescribed anticoagulant
B. Measuring and recording vital signs on a stable patient
C. Assessing a patient's wound for signs of infection
D. Evaluating a patient's response to a blood transfusion
Correct Answer: B
Rationale: Measuring and recording vital signs on a stable patient falls within the UAP scope of practice.
UAP are trained to perform routine measurements and report findings to the RN. The RN retains
responsibility for interpreting the data and making clinical decisions. Delegation of this task follows the five
rights of delegation: right task, right circumstance, right person, right direction, and right supervision.
Why Wrong: A involves patient teaching, which requires RN-level knowledge and assessment of learning
readiness. C requires clinical judgment and assessment skills beyond UAP scope. D involves evaluation of a
potentially life-threatening situation requiring RN assessment and critical thinking.
Reference: ANA Principles for Delegation (2026); NCSBN Delegation Guidelines; Marquis & Huston, Ch. 14.
5. During a shift, a nurse receives orders from a provider that appear to be incorrect. Which
action should the nurse take first?
A. Refuse to carry out the order and document the refusal
B. Clarify the order with the prescribing provider before implementation
C. Administer the medication as ordered and monitor the patient closely
, D. Report the provider to the nursing supervisor immediately
Correct Answer: B
Rationale: When a nurse questions an order, the first action is to clarify the order with the prescribing
provider. This promotes patient safety, upholds professional accountability, and supports collaborative
communication. The nurse has a professional and legal obligation to verify unclear or potentially harmful
orders before implementation. Clarification may reveal a misunderstanding, a documentation error, or a
genuine error that needs correction.
Why Wrong: A is premature; the nurse should first attempt clarification before refusing. C endangers the
patient by administering a potentially incorrect order. D is an escalation that should occur only after direct
communication fails or a patient safety event has occurred.
Reference: ANA Code of Ethics (2025), Provision 3; State Nurse Practice Acts; Marquis & Huston, Ch. 9.
6. A nurse is prioritizing care for the following patients. Which patient should be seen last?
A. A patient with chest pain rated 8/10
B. A patient with a blood glucose of 55 mg/dL who is diaphoretic
C. A patient requesting a dietary consultation
D. A patient with a new onset of atrial fibrillation
Correct Answer: C
Rationale: The patient requesting a dietary consultation is the lowest priority among the options presented.
Using the ABC framework and acuity-based prioritization, chest pain, hypoglycemia, and new-onset cardiac
dysrhythmia all represent urgent or emergent clinical situations requiring immediate intervention. A dietary
consultation is an important but non-urgent need that can be safely deferred until acute issues are addressed.
Why Wrong: A represents potential cardiac ischemia requiring immediate assessment. B represents severe
hypoglycemia, a medical emergency requiring rapid intervention. C represents a new cardiac dysrhythmia
requiring prompt assessment and monitoring.
Reference: Marquis & Huston (2026), Ch. 12; AACN Synergy Model; NCLEX-RN Test Plan.
7. Which principle is most important when delegating nursing tasks?
A. The delegator transfers accountability for the outcome to the delegatee
B. The delegator retains accountability for the delegated task while the delegatee is responsible for
performing it
C. Only tasks that the delegatee prefers should be delegated
D. Delegation can occur without supervision if the delegatee is experienced
Correct Answer: B
Rationale: The fundamental principle of delegation is that the RN retains accountability for the overall
nursing care and outcomes, even when specific tasks are delegated. The delegatee is responsible for performing
the assigned task competently and reporting back. This distinction is critical for patient safety, professional
standards, and legal protection. The ANA Principles for Delegation clearly state that accountability cannot be
transferred.
Why Wrong: A is incorrect because accountability cannot be transferred; the RN always retains it. C is not a
valid delegation principle; preference does not determine scope of practice. D violates the right to supervision;
all delegated tasks require appropriate oversight regardless of experience.
Reference: ANA Principles for Delegation (2026); NCSBN Joint Statement on Delegation; Marquis & Huston,
Ch. 14.
8. A nurse manager is implementing a new evidence-based fall prevention protocol. Which
strategy demonstrates effective change management?
A. Mandating immediate compliance without staff input
B. Engaging staff in the planning process and providing education before implementation
C. Waiting for all staff to express interest before beginning any changes
D. Implementing changes only on one shift and ignoring other shifts
Correct Answer: B
2026/2027 Edition
80 Questions and Answers with Rationales
Verified | Aligned with Elsevier HESI Leadership & Management Curriculum
Next Generation NCLEX (NGN) Standards Compliant
Key Features
Delegation, prioritization, and assignment of nursing tasks
Quality improvement, incident reporting, and change management
Legal, ethical, and professional responsibilities of the nurse
Conflict resolution, communication, and interdisciplinary collaboration
Resource management, staffing, and healthcare delivery systems
Updates for 2026
Updated ANA Standards: The 2026 American Nurses Association standards for nursing professional
development and shared governance have been integrated, reflecting the latest expectations for nurse autonomy,
evidence-based practice, and collaborative decision-making within healthcare organizations.
Revised 2026 National Patient Safety Goals (NPSGs): The Joint Commission's updated NPSGs now
place heightened emphasis on clinical escalation protocols, rapid response activation, and early recognition of
patient deterioration, requiring nurses to demonstrate competency in these critical safety domains.
New Elsevier Frameworks: Elsevier has introduced updated frameworks for managing nurse burnout,
promoting resilience, and preventing workplace violence, recognizing the impact of workforce well-being on
patient safety and care quality outcomes.
Abstract
This comprehensive document presents an 80-question actual exam designed to evaluate competency across the
core domains of nursing leadership and management as defined by the 2026/2027 Elsevier HESI Leadership
and Management curriculum and aligned with Next Generation NCLEX (NGN) standards. The examination
encompasses five critical domains: Delegation and Prioritization, Quality Improvement and Patient Safety, Legal
Ethical and Professional Issues, Communication and Conflict Management, and Resource Management and
Healthcare Systems. Each question is accompanied by a detailed rationale explaining the correct answer and an
analysis of why the distractors are incorrect, supported by references to current nursing leadership literature,
ANA standards, and evidence-based clinical guidelines. The content emphasizes effective delegation practices,
quality and safety initiatives, ethical decision-making frameworks, and the nurse manager's role in optimizing
patient care outcomes and team dynamics. This resource is designed to prepare nursing candidates for the HESI
Leadership actual exam while reinforcing the clinical judgment and professional competencies essential for
contemporary nursing leadership practice.
Keywords
HESI Leadership, Nursing Management, Delegation, Prioritization, Quality Improvement, Change Management,
Legal/Ethical Issues, Conflict Resolution, NGN
,Content Area Overview
Content Area Questions Key Topics Weight
Delegation & 1-16 Five rights of delegation, 20%
Prioritization scope of practice, ABC
prioritization, task
assignment, supervision
Quality Improvement & 17-32 PDSA cycle, incident 20%
Patient Safety reporting, just culture,
root cause analysis,
NPSGs, clinical
escalation
Legal, Ethical & 33-48 Autonomy, HIPAA, 20%
Professional Issues informed consent,
advance directives,
mandatory reporting,
malpractice
Communication & 49-64 SBAR, CUS, conflict 20%
Conflict Management resolution strategies,
therapeutic
communication, handoff
communication
Resource Management & 65-80 Budgeting, staffing 20%
Healthcare Systems models, shared
governance, value-based
care, benchmarking,
Magnet designation
Examination Questions
Domain: Delegation & Prioritization
1. A registered nurse (RN) on a medical-surgical unit is caring for five patients. Which patient
should the RN assess first?
A. A patient requesting pain medication for a chronic condition
B. A patient with a new onset of shortness of breath and decreased oxygen saturation
C. A patient who is scheduled for discharge later today
D. A patient who needs assistance with ambulation after surgery
Correct Answer: B
Rationale: Using the ABC (Airway, Breathing, Circulation) framework and Maslow's hierarchy of needs, a
patient with new-onset shortness of breath and decreased oxygen saturation represents the highest priority.
This patient may be experiencing a life-threatening respiratory compromise requiring immediate assessment
and intervention to ensure adequate oxygenation and ventilation.
Why Wrong: A is a chronic need that, while important, is not life-threatening. C is a routine discharge
process that can be addressed after acute needs. D is a standard postoperative mobility need that is not
emergent.
Reference: Marquis, B.L. & Huston, C.J. (2026). Leadership Roles and Management Functions in Nursing
(12th ed.), Ch. 12; ANA Standards of Practice, Standard 5.
2. The charge nurse is delegating tasks to a licensed practical nurse (LPN) and an unlicensed
assistive personnel (UAP). Which task is most appropriate to delegate to the LPN?
A. Ambulating a stable postoperative patient
B. Administering oral medications to a stable patient
, C. Developing a nursing care plan for a newly admitted patient
D. Providing initial health teaching to a patient with a new diabetes diagnosis
Correct Answer: B
Rationale: LPNs are licensed to administer oral medications to stable patients under the supervision of an
RN. This falls within their scope of practice as defined by state nurse practice acts. The RN retains
accountability for the overall plan of care and must ensure the LPN is competent to perform this specific task,
but medication administration to stable patients is a delegated nursing function the LPN is educationally
prepared to perform.
Why Wrong: A is within UAP scope and does not require LPN licensure. C requires RN-level assessment,
critical thinking, and nursing diagnosis, which is outside the LPN scope. D involves initial teaching requiring
comprehensive RN assessment and evaluation of learning readiness.
Reference: ANA Principles for Delegation (2026); NCSBN Decision-Making Framework; Marquis & Huston,
Ch. 14.
3. A nurse manager receives multiple patient complaints about delayed responses to call lights.
Which action should the nurse manager take first?
A. Implement a new staffing model immediately
B. Gather data on call light response times and patterns
C. Discipline the nursing staff for delayed responses
D. Reassign staff to different patient assignments
Correct Answer: B
Rationale: The nurse manager must first gather objective data to understand the scope, timing, and
contributing factors of the problem before implementing solutions. This evidence-based approach aligns with
quality improvement methodologies such as Plan-Do-Study-Act (PDSA), ensuring that interventions address
root causes rather than symptoms. Premature action without data analysis may worsen the problem or create
new issues.
Why Wrong: A is premature without data analysis; a new staffing model may not address the actual cause.
C is punitive and does not address systemic issues; it may also reduce morale. D is a temporary fix that does
not address underlying workflow or staffing problems.
Reference: Marquis & Huston (2026), Ch. 20; ANA Leadership Standards; IHI Quality Improvement
Framework.
4. An RN is assigned to care for four patients. Which task can be safely delegated to UAP?
A. Teaching a patient about a newly prescribed anticoagulant
B. Measuring and recording vital signs on a stable patient
C. Assessing a patient's wound for signs of infection
D. Evaluating a patient's response to a blood transfusion
Correct Answer: B
Rationale: Measuring and recording vital signs on a stable patient falls within the UAP scope of practice.
UAP are trained to perform routine measurements and report findings to the RN. The RN retains
responsibility for interpreting the data and making clinical decisions. Delegation of this task follows the five
rights of delegation: right task, right circumstance, right person, right direction, and right supervision.
Why Wrong: A involves patient teaching, which requires RN-level knowledge and assessment of learning
readiness. C requires clinical judgment and assessment skills beyond UAP scope. D involves evaluation of a
potentially life-threatening situation requiring RN assessment and critical thinking.
Reference: ANA Principles for Delegation (2026); NCSBN Delegation Guidelines; Marquis & Huston, Ch. 14.
5. During a shift, a nurse receives orders from a provider that appear to be incorrect. Which
action should the nurse take first?
A. Refuse to carry out the order and document the refusal
B. Clarify the order with the prescribing provider before implementation
C. Administer the medication as ordered and monitor the patient closely
, D. Report the provider to the nursing supervisor immediately
Correct Answer: B
Rationale: When a nurse questions an order, the first action is to clarify the order with the prescribing
provider. This promotes patient safety, upholds professional accountability, and supports collaborative
communication. The nurse has a professional and legal obligation to verify unclear or potentially harmful
orders before implementation. Clarification may reveal a misunderstanding, a documentation error, or a
genuine error that needs correction.
Why Wrong: A is premature; the nurse should first attempt clarification before refusing. C endangers the
patient by administering a potentially incorrect order. D is an escalation that should occur only after direct
communication fails or a patient safety event has occurred.
Reference: ANA Code of Ethics (2025), Provision 3; State Nurse Practice Acts; Marquis & Huston, Ch. 9.
6. A nurse is prioritizing care for the following patients. Which patient should be seen last?
A. A patient with chest pain rated 8/10
B. A patient with a blood glucose of 55 mg/dL who is diaphoretic
C. A patient requesting a dietary consultation
D. A patient with a new onset of atrial fibrillation
Correct Answer: C
Rationale: The patient requesting a dietary consultation is the lowest priority among the options presented.
Using the ABC framework and acuity-based prioritization, chest pain, hypoglycemia, and new-onset cardiac
dysrhythmia all represent urgent or emergent clinical situations requiring immediate intervention. A dietary
consultation is an important but non-urgent need that can be safely deferred until acute issues are addressed.
Why Wrong: A represents potential cardiac ischemia requiring immediate assessment. B represents severe
hypoglycemia, a medical emergency requiring rapid intervention. C represents a new cardiac dysrhythmia
requiring prompt assessment and monitoring.
Reference: Marquis & Huston (2026), Ch. 12; AACN Synergy Model; NCLEX-RN Test Plan.
7. Which principle is most important when delegating nursing tasks?
A. The delegator transfers accountability for the outcome to the delegatee
B. The delegator retains accountability for the delegated task while the delegatee is responsible for
performing it
C. Only tasks that the delegatee prefers should be delegated
D. Delegation can occur without supervision if the delegatee is experienced
Correct Answer: B
Rationale: The fundamental principle of delegation is that the RN retains accountability for the overall
nursing care and outcomes, even when specific tasks are delegated. The delegatee is responsible for performing
the assigned task competently and reporting back. This distinction is critical for patient safety, professional
standards, and legal protection. The ANA Principles for Delegation clearly state that accountability cannot be
transferred.
Why Wrong: A is incorrect because accountability cannot be transferred; the RN always retains it. C is not a
valid delegation principle; preference does not determine scope of practice. D violates the right to supervision;
all delegated tasks require appropriate oversight regardless of experience.
Reference: ANA Principles for Delegation (2026); NCSBN Joint Statement on Delegation; Marquis & Huston,
Ch. 14.
8. A nurse manager is implementing a new evidence-based fall prevention protocol. Which
strategy demonstrates effective change management?
A. Mandating immediate compliance without staff input
B. Engaging staff in the planning process and providing education before implementation
C. Waiting for all staff to express interest before beginning any changes
D. Implementing changes only on one shift and ignoring other shifts
Correct Answer: B
