1
HESI Exit Exam Crisis Management &
Code Response | Critical Nursing
Scenarios
Table of Contents
Subtopic 1: Immediate Assessment and Response in Clinical Crisis................2
Subtopic 2: Advanced Life Support Procedures and Role Delegation in Code
Situations.......................................................................................................11
Subtopic 3: Code Blue Activation Protocols and System Readiness...............21
Subtopic 4: Legal, Ethical, and Documentation Aspects of Crisis Response. .30
Subtopic 5: Legal, Ethical, and Documentation Aspects of Crisis and Code
Response.......................................................................................................39
Subtopic 6: Emergency Department (ED) Crisis Triage and Mass Casualty
Management..................................................................................................49
Subtopic 7: Emergency Preparedness and Mass Casualty Triage..................57
Subtopic 8: Emergency Equipment Usage and Safety Protocols....................67
Subtopic 9: Triage and Mass Casualty Incident (MCI) Management...............76
Subtopic 10: Psychological Support and Debriefing After Critical Events......85
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Subtopic 1: Immediate Assessment and
Response in Clinical Crisis
Question 1
A nurse enters a patient’s room and finds them unresponsive and pulseless.
What is the nurse’s first action?
A. Call the family
B. Begin chest compressions
C. Activate the emergency response system (code blue)
D. Check for medical history
Correct Answer: C. Activate the emergency response system (code blue)
Rationale: Immediate activation of the code blue system ensures rapid
response by the resuscitation team. Chest compressions follow immediately
after calling for help per BLS protocol.
Question 2
During a rapid response event, the nurse's role in supporting airway
management includes:
A. Administering IV medications
B. Providing manual ventilation using a bag-valve-mask
C. Calling the physician
D. Recording the time of medication administration
Correct Answer: B. Providing manual ventilation using a bag-valve-mask
, 3
Rationale: While the code team handles advanced airway, the bedside nurse
may assist with basic life support like bag-mask ventilation while awaiting
advanced help.
Question 3
Which sign indicates the need to escalate a rapid response to a full code?
A. Restlessness
B. Elevated blood pressure
C. Absence of pulse and respirations
D. Oxygen saturation of 94%
Correct Answer: C. Absence of pulse and respirations
Rationale: Lack of vital signs signifies cardiac or respiratory arrest, prompting
full code activation.
Question 4
What is the priority assessment when a nurse suspects a stroke?
A. Blood glucose
B. Cardiac enzymes
C. Facial droop, arm weakness, and speech difficulty
D. Respiratory rate
Correct Answer: C. Facial droop, arm weakness, and speech difficulty
Rationale: FAST (Face, Arm, Speech, Time) is the primary stroke assessment
protocol for early recognition and treatment.
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Question 5
In the event of a seizure in a patient in bed, what is the nurse’s immediate
priority?
A. Insert an oral airway
B. Administer IV diazepam
C. Protect the patient from injury
D. Call the healthcare provider
Correct Answer: C. Protect the patient from injury
Rationale: Safety is the top priority. Administering medications or calling for
help comes after ensuring the patient does not fall or hit objects.
Question 6
A client becomes cyanotic and gasps for air after eating. What is the nurse's
immediate response?
A. Perform abdominal thrusts (Heimlich maneuver)
B. Start rescue breathing
C. Initiate chest compressions
D. Encourage coughing
Correct Answer: A. Perform abdominal thrusts (Heimlich maneuver)
Rationale: Cyanosis and gasping indicate airway obstruction, requiring
immediate intervention using abdominal thrusts.
Question 7
Which lab value, if critically low, most increases risk for cardiac arrest?
HESI Exit Exam Crisis Management &
Code Response | Critical Nursing
Scenarios
Table of Contents
Subtopic 1: Immediate Assessment and Response in Clinical Crisis................2
Subtopic 2: Advanced Life Support Procedures and Role Delegation in Code
Situations.......................................................................................................11
Subtopic 3: Code Blue Activation Protocols and System Readiness...............21
Subtopic 4: Legal, Ethical, and Documentation Aspects of Crisis Response. .30
Subtopic 5: Legal, Ethical, and Documentation Aspects of Crisis and Code
Response.......................................................................................................39
Subtopic 6: Emergency Department (ED) Crisis Triage and Mass Casualty
Management..................................................................................................49
Subtopic 7: Emergency Preparedness and Mass Casualty Triage..................57
Subtopic 8: Emergency Equipment Usage and Safety Protocols....................67
Subtopic 9: Triage and Mass Casualty Incident (MCI) Management...............76
Subtopic 10: Psychological Support and Debriefing After Critical Events......85
, 2
Subtopic 1: Immediate Assessment and
Response in Clinical Crisis
Question 1
A nurse enters a patient’s room and finds them unresponsive and pulseless.
What is the nurse’s first action?
A. Call the family
B. Begin chest compressions
C. Activate the emergency response system (code blue)
D. Check for medical history
Correct Answer: C. Activate the emergency response system (code blue)
Rationale: Immediate activation of the code blue system ensures rapid
response by the resuscitation team. Chest compressions follow immediately
after calling for help per BLS protocol.
Question 2
During a rapid response event, the nurse's role in supporting airway
management includes:
A. Administering IV medications
B. Providing manual ventilation using a bag-valve-mask
C. Calling the physician
D. Recording the time of medication administration
Correct Answer: B. Providing manual ventilation using a bag-valve-mask
, 3
Rationale: While the code team handles advanced airway, the bedside nurse
may assist with basic life support like bag-mask ventilation while awaiting
advanced help.
Question 3
Which sign indicates the need to escalate a rapid response to a full code?
A. Restlessness
B. Elevated blood pressure
C. Absence of pulse and respirations
D. Oxygen saturation of 94%
Correct Answer: C. Absence of pulse and respirations
Rationale: Lack of vital signs signifies cardiac or respiratory arrest, prompting
full code activation.
Question 4
What is the priority assessment when a nurse suspects a stroke?
A. Blood glucose
B. Cardiac enzymes
C. Facial droop, arm weakness, and speech difficulty
D. Respiratory rate
Correct Answer: C. Facial droop, arm weakness, and speech difficulty
Rationale: FAST (Face, Arm, Speech, Time) is the primary stroke assessment
protocol for early recognition and treatment.
, 4
Question 5
In the event of a seizure in a patient in bed, what is the nurse’s immediate
priority?
A. Insert an oral airway
B. Administer IV diazepam
C. Protect the patient from injury
D. Call the healthcare provider
Correct Answer: C. Protect the patient from injury
Rationale: Safety is the top priority. Administering medications or calling for
help comes after ensuring the patient does not fall or hit objects.
Question 6
A client becomes cyanotic and gasps for air after eating. What is the nurse's
immediate response?
A. Perform abdominal thrusts (Heimlich maneuver)
B. Start rescue breathing
C. Initiate chest compressions
D. Encourage coughing
Correct Answer: A. Perform abdominal thrusts (Heimlich maneuver)
Rationale: Cyanosis and gasping indicate airway obstruction, requiring
immediate intervention using abdominal thrusts.
Question 7
Which lab value, if critically low, most increases risk for cardiac arrest?
