HESI E2 HESI Exit Exam - Set 1 - Part 1

Correct Answer: Verify the client using two identifiers

Verifying the client with two unique identifiers such as full name and date of birth must precede every admission step. It confirms that subsequent assessments and orders link to the correct person. Option a is incorrect because medication reconciliation is a required admission task that follows identity verification. Reconciling for a wrongly identified client could pull the wrong home list into the chart and trigger downstream errors at every care transition. Option b is incorrect because orientation supports comfort and call-light use, yet it is a courtesy step rather than a safety prerequisite. Without confirmed identity, even orientation could be given to the wrong patient, undermining the admission record. Option d is incorrect because the head-to-toe assessment is the RN's responsibility, but performing it on an unverified client could attach baseline findings to the wrong chart. Identity verification anchors every assessment finding to the correct medical record.

Correct Answer: Direct nurse-to-nurse SBAR bedside report

Warm bedside SBAR allows the receiving nurse to visualize lines, drains, and the client while asking clarifying questions. This direct exchange is the gold standard for transfers and reduces sentinel events linked to communication failures. Option b is incorrect because a fax delivers static information with no opportunity for back-and-forth clarification. Important details about lines, contingency plans, or pending labs are easily missed when the receiver cannot ask questions in real time. Option c is incorrect because reporting at the station keeps the client out of the loop and prevents visual verification of equipment and condition. Bedside handoff is preferred precisely because it pairs verbal exchange with direct observation. Option d is incorrect because chart review alone does not equal handoff. Critical recent events, contingency plans, and the family's concerns rarely live cleanly in the EHR, so a structured verbal exchange remains essential.

Correct Answer: New admission with chest pain

A newly admitted client with chest pain is unstable and requires the RN's initial assessment, clinical judgment, and cardiac evaluation. Initial assessment of new admissions and care of unstable clients cannot be delegated to an LPN or UAP. Option a is incorrect because a stable client awaiting discharge tomorrow is predictable and routine. While the RN remains accountable for the discharge plan, the LPN can safely manage day-to-day care for a client in this stage of the stay. Option c is incorrect because bathing falls clearly within the UAP scope for a stable client. Delegating this hygiene task frees the RN to focus on more complex assessments and unstable clients on the assignment list right now. Option d is incorrect because routine vital signs on a stable client every shift are appropriate to delegate to the UAP. The assignment requires no nursing judgment about a changing condition that would push the task back to the RN.

Correct Answer: Honor the refusal and notify provider

Autonomy of a competent adult must be respected even when refusal carries life-threatening risk. The nurse honors the decision, documents the refusal, and notifies the provider so the team can adjust the plan and explore alternatives. Option a is incorrect because urging family to pressure the client violates autonomy and shifts decision-making away from the person whose body is involved. Advocacy supports the client's voice, not the family's preference, when the client has capacity. Option b is incorrect because administering a refused transfusion while the client sleeps constitutes battery, an intentional tort involving unauthorized touching. Capacity does not lapse during sleep, and the prior refusal still binds the team. Option c is incorrect because simply documenting for legal review skips the immediate clinical steps the nurse must take. The provider needs to be notified now so alternatives such as cell salvage or volume expansion can be considered.

Correct Answer: Honor the client's current signed wishes

While the client retains capacity, their expressed wishes prevail and the named proxy will act only if capacity is lost. The signed durable power of attorney for healthcare documents the client's choice and the spouse cannot override it. Option a is incorrect because shifting decision-making to the spouse contradicts the client's signed designation and would substitute a non-designated surrogate for the legally chosen proxy. The advance directive controls the order of decision-makers if capacity is later lost. Option b is incorrect because the ethics committee provides guidance for genuinely conflicting cases, not for situations where the legal hierarchy is already clear. Routing a clear case to ethics delays care and misuses the consultation resource. Option d is incorrect because the document belongs in the client's chart so the entire care team can act on it. Sending the only copy home with the daughter would hide the directive from staff during a future emergency.

Correct Answer: Gown and gloves

Contact precautions for a colonized wound require gown and gloves on room entry to interrupt direct and indirect transmission. A mask is not routinely needed unless splash exposure or droplet transmission is also anticipated during the encounter. Option b is incorrect because a surgical mask is the hallmark of droplet precautions, used within six feet of the client. A mask alone without a gown leaves the nurse's uniform exposed to a contact pathogen at every reach. Option c is incorrect because an N95 respirator is used for airborne pathogens such as active tuberculosis, measles, or varicella. An MDRO transmitted by contact does not warrant this level of respiratory protection or the associated negative-pressure room. Option d is incorrect because this combination is suited to a procedure with splash risk, not routine contact entry. Adding a mask and goggles for an uncomplicated wound dressing wastes supplies and creates a false sense of expanded protection.

Correct Answer: Place a surgical mask on client

During transport for airborne precautions the client wears a surgical mask, not an N95, because respirator-grade protection is not appropriate as source control. Staff continue wearing fit-tested N95 respirators and notify the receiving department in advance. Option a is incorrect because an N95 worn by an ill client lacks an exhalation valve check designed for source control. Source control masks are designed to contain the wearer's respiratory droplets, which is the surgical mask's role here. Option b is incorrect because the airborne infection isolation room door must stay closed to preserve negative pressure. Leaving it open releases contaminated air into the corridor and defeats the engineered ventilation that defines airborne isolation rooms. Option c is incorrect because route selection alone does not contain airborne droplet nuclei, which travel long distances on air currents. A surgical mask on the client and an N95 on staff are the actual barriers required during tr

Correct Answer: Sterile insertion with daily necessity review

Sterile insertion, smallest functional size, and daily review of necessity are the core CAUTI bundle elements. Daily assessment ensures the catheter is removed as soon as the indication resolves, which directly reduces infection risk. Option a is incorrect because oversized catheters cause urethral trauma and bypass urine that can pool around the catheter. The bundle calls for the smallest size that allows adequate drainage, the opposite of choosing the largest available. Option c is incorrect because the drainage bag must hang below the bladder at all times to prevent retrograde flow of contaminated urine. Same-level placement allows urine to drift back toward the bladder and seed an infection. Option d is incorrect because routine meatal antisepsis with chlorhexidine is not part of the CAUTI bundle, which calls for soap and water perineal care. Adding chlorhexidine offers no benefit and may cause local irritation.

Correct Answer: Lowest locked bed position

Lowering and locking the bed reduces the height a client could fall from and prevents the bed from rolling on transfer. This is part of universal fall precautions for every client, regardless of formal risk score. Option b is incorrect because restraints are a last-resort intervention that require a provider's order, documented failure of less restrictive measures, and ongoing monitoring. Preventive restraint use increases harm and is never part of universal precautions. Option c is incorrect because raising all four side rails meets the definition of a restraint since the client cannot exit the bed. Doing so without an order risks entrapment, strangulation, and a regulatory violation under federal standards. Option d is incorrect because sedatives are listed among fall-risk medications under the Beers Criteria. Adding a sedative for an unsteady older adult would increase the very risk the nurse is trying to prevent on this admission.

Correct Answer: Read the order back word for word

Telephone orders require the nurse to write the order, read it back verbatim, and obtain provider confirmation. This read-back step catches mistranscription and is required before any verbal order can be safely implemented. Option a is incorrect because skipping read-back leaves the order unverified and shifts all responsibility for transcription errors onto the nurse. Documentation after the fact does not substitute for the verification step that protects against misheard doses. Option b is incorrect because the unit secretary is not the licensed receiver of a telephone order and cannot verify it with the provider. Entering the order through a clerk also bypasses the read-back step that the standard requires. Option d is incorrect because telephone orders are accepted in urgent situations precisely so that care is not delayed. Refusing the order outright when read-back is the established practice would interrupt timely treatment without reducing risk.

Correct Answer: Notify charge nurse and document

Suspected diversion of a controlled substance is a serious patient safety and legal concern. The nurse must report through the chain of command immediately and document specific factual observations such as time, location, and what was seen. Option a is incorrect because confronting a suspected diverting colleague alone after shift can escalate the situation and tip off the colleague to alter evidence. The standard response is to report up the chain so investigators can act safely. Option b is incorrect because diversion places patients at risk of inadequate pain control and a potentially impaired practitioner remains on the unit. Waiting for repeat behavior delays protection of patients and may make later investigation harder to substantiate. Option c is incorrect because anonymous notes bypass the formal chain of command and provide no accountability for accurate factual observations. Whistleblower protections rely on documented, named reports through approved channels rather than an

Correct Answer: Stop infusion; prepare IM epinephrine

Anaphylaxis requires stopping the trigger first and administering intramuscular epinephrine in the vastus lateralis as the first-line drug. Antihistamines, steroids, and bronchodilators are adjuncts that follow epinephrine and never replace it during the initial response. Option b is incorrect because diphenhydramine is an H1 blocker adjunct that does not reverse the laryngeal edema or shock driving anaphylaxis. Giving an antihistamine first delays the only drug proven to halt the reaction, which is epinephrine. Option c is incorrect because lowering the head of the bed without addressing the trigger does nothing to interrupt the systemic reaction. Positioning has a role after epinephrine, but stopping the infusion and giving the drug come first. Option d is incorrect because paging and documenting are necessary but secondary tasks during anaphylaxis. The first action belongs to the bedside nurse, who must stop the trigger and treat the airway and circulatory threat immediately at the

Correct Answer: Routine ambulation for stable client

Ambulation of a stable client is a routine, predictable task that falls clearly within the UAP scope of practice. The RN remains accountable, monitors the outcome, and reassesses if the client's condition changes during the shift. Option a is incorrect because reinforcing teaching is within the LPN scope after the RN has initiated the original teaching. Delegating any teaching to a UAP exceeds their role since they cannot judge gaps in client understanding. Option c is incorrect because oral medication administration is reserved for licensed staff such as the RN or LPN in most states. UAPs do not have the legal authority to administer prescription medications under any standard delegation framework. Option d is incorrect because urinary catheter insertion is an invasive procedure requiring sterile technique and licensed assessment. This skill falls within the RN and LPN scope of practice, not the UAP's defined activities under typical delegation.

Correct Answer: Wash hands with soap and water

C. difficile produces spores that alcohol-based rubs cannot kill. Soap and water must be used after caring for clients with C. difficile because the mechanical action of washing physically removes spores from the skin surface during rinsing. Option a is incorrect because alcohol-based hand rub is ineffective against bacterial spores. Choosing it here would leave the nurse's hands contaminated with C. difficile spores that can be carried to the next client and cause cross-transmission. Option b is incorrect because gloves are not a substitute for hand hygiene and microbreaches occur during glove use. Skipping hand hygiene after glove removal is a frequent root cause of healthcare-associated infections and never acceptable. Option d is incorrect because chlorhexidine wipes are designed for skin antisepsis before procedures, not for routine hand hygiene after spore-forming pathogens. Soap-and-water washing remains the validated approach for C. difficile exposure today.

Correct Answer: Move the client out

The RACE acronym sequences fire response as Rescue, Alarm, Contain, and Extinguish. Removing the client from immediate danger is the first action because no other step protects this person from smoke and heat exposure quickly enough. Option a is incorrect because pulling the alarm precedes containment and extinguishment but follows rescue. Sounding the alarm while a non-ambulatory client remains in the smoke-filled room leaves the most immediate threat unaddressed at the bedside. Option b is incorrect because containing the fire by closing the door becomes safe only after the client is out. Closing the door first would trap the client inside with the source of smoke and possibly with active flames nearby. Option c is incorrect because attempting to extinguish belongs to the final step of RACE and applies to small, contained fires only. Reaching for the extinguisher before rescue leaves a non-ambulatory client at the highest immediate risk.

Correct Answer: Have client state name and birthdate

Two acceptable identifiers, asked open-endedly and compared to the wristband, meet the safety goal. Asking the client to state name and date of birth avoids yes-or-no errors and aligns with The Joint Commission's standard for medication administration. Option b is incorrect because room and bed numbers are explicitly excluded from acceptable identifiers. Clients are moved between rooms during stays, and a chart left at the wrong bedside could easily lead to administering medications to the wrong person. Option c is incorrect because yes-or-no questions invite a confused or hard-of-hearing client to nod along incorrectly. The standard requires the client to state the identifying information, not simply confirm an assumption the nurse has voiced. Option d is incorrect because diagnosis is not a patient identifier and may be shared across many clients on the unit. Verifying disease does nothing to confirm the identity of the specific person about to receive medication this morning.

Correct Answer: Ask receiver to synthesize back

The final S in I-PASS stands for synthesis by the receiver, who summarizes the handoff back to the off-going nurse. This step confirms shared understanding and is the single most important safety check in the framework. Option a is incorrect because documenting handoff time is a workflow step that follows the structured exchange. Documentation cannot substitute for synthesis because it records that report happened without confirming that the receiver actually understood the contents. Option b is incorrect because signing the MAR is part of medication accountability, not part of handoff communication. Mixing the two records would not verify receiver comprehension and could blur responsibility for the next medication doses safely. Option d is incorrect because contacting the provider is appropriate when condition changes occur, not during routine end-of-shift handoff. The receiver, not the provider, must demonstrate understanding for the handoff to be considered safely complete.

Correct Answer: Gown, mask, goggles, gloves

Correct PPE donning order is hand hygiene, then gown, then mask or respirator, then goggles, then gloves last. Gloves are donned last so they can be pulled over the gown cuffs and remain the cleanest. Option a is incorrect because gloves are never donned first. Wearing gloves while handling other PPE contaminates the gown ties and mask straps and forces the wearer to remove and replace items, defeating the purpose of the sequence. Option c is incorrect because donning the mask before the gown forces the wearer to lift the gown over the head with the face already covered. This sequence often dislodges the mask and creates gaps before the gown is tied. Option d is incorrect because starting with goggles places eye protection on before the face mask, leaving the mask straps to disturb the goggle fit. The standard order keeps each piece in place by adding the next layer outward sequentially.

Correct Answer: Decline and notify charge nurse

The nurse must recognize personal scope limitations and decline an assignment for which competency has not been validated. Notifying the charge nurse allows reassignment to a chemotherapy-certified nurse and prevents a patient safety event from occurring this shift. Option a is incorrect because reading the protocol does not substitute for the formal competency training required for chemotherapy. Self-instruction immediately before a high-risk administration ignores the institutional validation process designed to prevent extravasation and dosing errors. Option b is incorrect because verbal coaching from a colleague does not transfer the formal certification required to hang chemotherapy. Two unprepared nurses create more risk, not less, and neither has the authority to validate competency at the bedside. Option c is incorrect because joint hands-on administration without certification still places the new nurse in an unsafe role. Sharing the task does not change the legal and safety r

Correct Answer: Acknowledge the right; notify provider

Refusal of care is a fundamental client right that remains intact during hospitalization. The nurse acknowledges the right, documents the refusal with reason, and notifies the provider so that alternatives can be discussed without coercion at the bedside. Option b is incorrect because hospital admission does not create a binding contract that strips a client of refusal rights. Coercive framing pressures the client into compliance and undermines the autonomy that the Patient Bill of Rights protects daily. Option c is incorrect because a written order does not override a competent client's decision. The order authorizes administration but does not eliminate the client's standing right to refuse any specific medication or treatment at any time. Option d is incorrect because administering a refused medication constitutes battery, the unauthorized touching of a person. Asking the client to refuse later does not validate the current decision and may erode trust with the care team f