1
Exit HESI PN Study Guide Things I Forget Practical
Nursing Exam Actual Exam 2026/2027 – Complete
Exam-Style Questions with Detailed Rationales | Pass
Guaranteed – A+ Graded
[SECTION 1: Safe & Effective Care Environment — Questions 1-20]
Q1: The charge nurse on a medical-surgical unit is making assignments for the shift. Which task
is most appropriate to delegate to the unlicensed assistive personnel (UAP)?
A. Administering a tap water enema to a client with constipation
B. Teaching a client how to use a glucose meter
C. Performing the initial admission assessment on a new client
D. Recording the intake and output for a stable client with heart failure [CORRECT]
Correct Answer: D
Rationale: Recording intake and output (I&O) is a standard task that falls within the scope of
practice for unlicensed assistive personnel (UAP) for stable clients, as it involves data collection
rather than clinical judgment or education. Administering an enema (A) requires nursing
judgment regarding client tolerance and procedure safety; teaching (B) is a nursing responsibility
requiring evaluation of learning; and the initial admission assessment (C) requires the critical
thinking and licensure of a registered nurse (RN) or licensed practical nurse (LPN). Delegating
I&O allows the nurse to focus on higher-level tasks while ensuring routine monitoring is
maintained.
Q2: A client is scheduled for a surgical procedure later in the day. The nurse enters the room to
obtain the informed consent signature and finds the client sedated after receiving a preoperative
medication. Which action should the nurse take?
A. Proceed with signing the consent form on the client's behalf
B. Ask a family member to sign the consent form for the client
C. Wait until the client is fully alert and awake to sign the form [CORRECT]
D. Call the surgeon to cancel the surgery immediately
,2
Correct Answer: C
Rationale: For informed consent to be valid, the client must be fully alert, oriented, and capable
of understanding the procedure, risks, and benefits; therefore, the nurse must wait until the
sedation wears off. Signing on behalf of the client (A) or asking a family member (B) is legally
invalid unless the client has a previously established legal guardian or durable power of attorney,
which is not implied here. Canceling the surgery (D) is a premature action that disrupts the
schedule; the immediate need is simply to wait for the client to regain capacity.
Q3: The nurse is caring for a client who has a "Do Not Resuscitate" (DNR) order in place. The
client suddenly develops difficulty breathing and loses consciousness. Which action is the
priority?
A. Call a code blue and initiate CPR immediately
B. Provide comfort measures and notify the healthcare provider [CORRECT]
C. Ask the family if they want the nurse to ignore the DNR order
D. Administer oxygen via non-rebreather mask at 15 L/min
Correct Answer: B
Rationale: When a valid DNR order is present, the nurse is ethically and legally obligated to
withhold resuscitative measures such as CPR; the priority shifts to providing comfort measures
(dignity, pain management, presence) and notifying the provider of the change in status.
Initiating CPR (A) violates the client's autonomous right to refuse treatment as documented in
the DNR. Asking the family (C) is inappropriate because the decision belongs to the client (or
their legal proxy), and the existing order must be followed until formally revoked. While oxygen
for comfort (D) might be appropriate, aggressive ventilation (non-rebreather) is often considered
a life-sustaining intervention inconsistent with DNR status unless specifically prescribed for
comfort.
Q4: A nurse is discussing client care with a colleague in the hospital cafeteria. Which statement
by the nurse violates the Health Insurance Portability and Accountability Act (HIPAA)?
A. "I had a busy day with four admissions."
B. "The client in room 304 is really upset about his cancer diagnosis." [CORRECT]
C. "My client is recovering well from surgery."
,3
D. "I need to check the chart before I give that medication."
Correct Answer: B
Rationale: HIPAA prohibits sharing any identifiable client information (such as room number,
diagnosis, or name) in public areas where others can overhear, as this compromises privacy and
confidentiality. General statements like having a busy day or a client recovering well (A and C)
do not reveal protected health information (PHI) or specific identities. While discussing care is
necessary for treatment, it must occur in private settings, not a cafeteria.
Q5: While performing an assessment on a 6-year-old child, the nurse notices multiple bruises on
the child’s back and buttocks in various stages of healing. The child's explanation is inconsistent
with the injuries. What is the nurse's legal obligation?
A. Confront the parents about the injuries immediately
B. Report the suspected abuse to the appropriate authorities [CORRECT]
C. Document the findings and wait for the next assessment
D. Ask the child to confirm if the parents hurt them
Correct Answer: B
Rationale: Nurses are mandatory reporters for suspected child abuse; if there is reasonable
suspicion (bruises in various stages, inconsistent explanation), the nurse must report it to Child
Protective Services or designated authorities per state law. Confronting the parents (A) can
escalate danger and compromise the investigation. Merely documenting (C) or questioning the
child further (D) without reporting delays necessary intervention and fails to meet the legal
mandate.
Q6: A nurse suspects a colleague is impaired by alcohol while on duty. The colleague smells of
alcohol and has difficulty documentation. What is the nurse’s priority action?
A. Confront the colleague and demand they go home
B. Report the suspicion to the nurse manager or supervisor immediately [CORRECT]
C. Ask another nurse to watch the colleague for the rest of the shift
D. Encourage the colleague to seek help after the shift ends
, 4
Correct Answer: B
Rationale: Patient safety is the priority; reporting an impaired colleague to a supervisor or
manager is the required action to ensure immediate removal from patient care. Confronting the
colleague (A) may lead to conflict or denial and does not immediately protect patients. Covering
for them or asking others to watch (C) enables the impairment and places patients at risk. While
encouraging help (D) is supportive, it does not address the immediate danger of the current shift.
Q7: The nurse is assessing a fall risk using the Morse Fall Scale. Which factor contributes to the
highest score on this scale?
A. History of falling [CORRECT]
B. Ambulatory aids
C. IV therapy
D. Weak gait
Correct Answer: A
Rationale: On the Morse Fall Scale, a history of falling immediately assigns a score of 25, which
is often the single highest weighted item, indicating a high risk for recurrence. Ambulatory aids
score 15-30 depending on if the client uses them fully or partially, IV therapy scores 20, and gait
scores vary (10-20). Identifying a history of falling allows the nurse to implement strict fall
prevention protocols immediately.
Q8: A client has a prescription for wrist restraints. The nurse applies the restraints and ensures
the client's safety. Which action is required for the continued use of restraints?
A. Renew the prescription every 8 hours
B. Perform a face-to-face evaluation of the client within 1 hour of application [CORRECT]
C. Tie the restraint straps to the side rails of the bed
D. Remove the restraints only once per shift for skin care
Correct Answer: B
According to The Joint Commission and CMS standards, a licensed independent practitioner
(LIP) or registered nurse must perform a face-to-face evaluation of the client within 1 hour of the
Exit HESI PN Study Guide Things I Forget Practical
Nursing Exam Actual Exam 2026/2027 – Complete
Exam-Style Questions with Detailed Rationales | Pass
Guaranteed – A+ Graded
[SECTION 1: Safe & Effective Care Environment — Questions 1-20]
Q1: The charge nurse on a medical-surgical unit is making assignments for the shift. Which task
is most appropriate to delegate to the unlicensed assistive personnel (UAP)?
A. Administering a tap water enema to a client with constipation
B. Teaching a client how to use a glucose meter
C. Performing the initial admission assessment on a new client
D. Recording the intake and output for a stable client with heart failure [CORRECT]
Correct Answer: D
Rationale: Recording intake and output (I&O) is a standard task that falls within the scope of
practice for unlicensed assistive personnel (UAP) for stable clients, as it involves data collection
rather than clinical judgment or education. Administering an enema (A) requires nursing
judgment regarding client tolerance and procedure safety; teaching (B) is a nursing responsibility
requiring evaluation of learning; and the initial admission assessment (C) requires the critical
thinking and licensure of a registered nurse (RN) or licensed practical nurse (LPN). Delegating
I&O allows the nurse to focus on higher-level tasks while ensuring routine monitoring is
maintained.
Q2: A client is scheduled for a surgical procedure later in the day. The nurse enters the room to
obtain the informed consent signature and finds the client sedated after receiving a preoperative
medication. Which action should the nurse take?
A. Proceed with signing the consent form on the client's behalf
B. Ask a family member to sign the consent form for the client
C. Wait until the client is fully alert and awake to sign the form [CORRECT]
D. Call the surgeon to cancel the surgery immediately
,2
Correct Answer: C
Rationale: For informed consent to be valid, the client must be fully alert, oriented, and capable
of understanding the procedure, risks, and benefits; therefore, the nurse must wait until the
sedation wears off. Signing on behalf of the client (A) or asking a family member (B) is legally
invalid unless the client has a previously established legal guardian or durable power of attorney,
which is not implied here. Canceling the surgery (D) is a premature action that disrupts the
schedule; the immediate need is simply to wait for the client to regain capacity.
Q3: The nurse is caring for a client who has a "Do Not Resuscitate" (DNR) order in place. The
client suddenly develops difficulty breathing and loses consciousness. Which action is the
priority?
A. Call a code blue and initiate CPR immediately
B. Provide comfort measures and notify the healthcare provider [CORRECT]
C. Ask the family if they want the nurse to ignore the DNR order
D. Administer oxygen via non-rebreather mask at 15 L/min
Correct Answer: B
Rationale: When a valid DNR order is present, the nurse is ethically and legally obligated to
withhold resuscitative measures such as CPR; the priority shifts to providing comfort measures
(dignity, pain management, presence) and notifying the provider of the change in status.
Initiating CPR (A) violates the client's autonomous right to refuse treatment as documented in
the DNR. Asking the family (C) is inappropriate because the decision belongs to the client (or
their legal proxy), and the existing order must be followed until formally revoked. While oxygen
for comfort (D) might be appropriate, aggressive ventilation (non-rebreather) is often considered
a life-sustaining intervention inconsistent with DNR status unless specifically prescribed for
comfort.
Q4: A nurse is discussing client care with a colleague in the hospital cafeteria. Which statement
by the nurse violates the Health Insurance Portability and Accountability Act (HIPAA)?
A. "I had a busy day with four admissions."
B. "The client in room 304 is really upset about his cancer diagnosis." [CORRECT]
C. "My client is recovering well from surgery."
,3
D. "I need to check the chart before I give that medication."
Correct Answer: B
Rationale: HIPAA prohibits sharing any identifiable client information (such as room number,
diagnosis, or name) in public areas where others can overhear, as this compromises privacy and
confidentiality. General statements like having a busy day or a client recovering well (A and C)
do not reveal protected health information (PHI) or specific identities. While discussing care is
necessary for treatment, it must occur in private settings, not a cafeteria.
Q5: While performing an assessment on a 6-year-old child, the nurse notices multiple bruises on
the child’s back and buttocks in various stages of healing. The child's explanation is inconsistent
with the injuries. What is the nurse's legal obligation?
A. Confront the parents about the injuries immediately
B. Report the suspected abuse to the appropriate authorities [CORRECT]
C. Document the findings and wait for the next assessment
D. Ask the child to confirm if the parents hurt them
Correct Answer: B
Rationale: Nurses are mandatory reporters for suspected child abuse; if there is reasonable
suspicion (bruises in various stages, inconsistent explanation), the nurse must report it to Child
Protective Services or designated authorities per state law. Confronting the parents (A) can
escalate danger and compromise the investigation. Merely documenting (C) or questioning the
child further (D) without reporting delays necessary intervention and fails to meet the legal
mandate.
Q6: A nurse suspects a colleague is impaired by alcohol while on duty. The colleague smells of
alcohol and has difficulty documentation. What is the nurse’s priority action?
A. Confront the colleague and demand they go home
B. Report the suspicion to the nurse manager or supervisor immediately [CORRECT]
C. Ask another nurse to watch the colleague for the rest of the shift
D. Encourage the colleague to seek help after the shift ends
, 4
Correct Answer: B
Rationale: Patient safety is the priority; reporting an impaired colleague to a supervisor or
manager is the required action to ensure immediate removal from patient care. Confronting the
colleague (A) may lead to conflict or denial and does not immediately protect patients. Covering
for them or asking others to watch (C) enables the impairment and places patients at risk. While
encouraging help (D) is supportive, it does not address the immediate danger of the current shift.
Q7: The nurse is assessing a fall risk using the Morse Fall Scale. Which factor contributes to the
highest score on this scale?
A. History of falling [CORRECT]
B. Ambulatory aids
C. IV therapy
D. Weak gait
Correct Answer: A
Rationale: On the Morse Fall Scale, a history of falling immediately assigns a score of 25, which
is often the single highest weighted item, indicating a high risk for recurrence. Ambulatory aids
score 15-30 depending on if the client uses them fully or partially, IV therapy scores 20, and gait
scores vary (10-20). Identifying a history of falling allows the nurse to implement strict fall
prevention protocols immediately.
Q8: A client has a prescription for wrist restraints. The nurse applies the restraints and ensures
the client's safety. Which action is required for the continued use of restraints?
A. Renew the prescription every 8 hours
B. Perform a face-to-face evaluation of the client within 1 hour of application [CORRECT]
C. Tie the restraint straps to the side rails of the bed
D. Remove the restraints only once per shift for skin care
Correct Answer: B
According to The Joint Commission and CMS standards, a licensed independent practitioner
(LIP) or registered nurse must perform a face-to-face evaluation of the client within 1 hour of the
