HESI E2 HESI Exit Exam - Set 1 - Part 2

Correct Answer: Standard, droplet, contact, airborne

For hospitalized pediatric pertussis cases, Saunders directs the use of standard, droplet, contact, and airborne precautions in combination. This layered approach addresses the multiple routes by which the organism can spread during inpatient pediatric care. Option a is incorrect because contact and standard precautions alone leave the respiratory droplet route uncovered. Pertussis spreads predominantly by respiratory droplets generated during coughing fits, so omitting droplet protection invites direct exposure to other clients and staff. Option c is incorrect because droplet alone fits adult pertussis but not the hospitalized pediatric case. The pediatric inpatient protocol layers additional precautions to address the closer caregiving contact and increased aerosolization risk during pediatric care delivery. Option d is incorrect because a standalone surgical mask under standard precautions is insufficient for pertussis. The combined approach is necessary to protect against droplet,

Correct Answer: Use maximal barrier precautions

Maximal barrier precautions, including cap, mask, sterile gown, sterile gloves, and a full body drape, are core to CLABSI prevention. The bundle also includes chlorhexidine skin antisepsis, optimal site selection, and daily review of line necessity. Option a is incorrect because chlorhexidine, not iodine, is the preferred skin antiseptic in the central line bundle. Iodine remains an alternative for chlorhexidine allergy, but it is not the standard choice for routine elective insertions on this unit. Option b is incorrect because the subclavian site is preferred over the jugular, and the femoral site has the highest CLABSI risk. Choosing the femoral site for convenience ignores the bundle's site selection guidance and increases infection probability. Option d is incorrect because hand hygiene precedes every element of the bundle, including sterile gowning. A sterile field cannot compensate for organisms transferred from unwashed hands to the field, supplies, or insertion site durin

Correct Answer: Release every two hours

Per Saunders, non-behavioral medical restraints require skin and neurovascular checks every thirty minutes and release of the safety device at least every two hours to allow range of motion, toileting, and circulation assessment at the bedside. Option a is incorrect because every twelve hours is far less frequent than the every-thirty-minutes assessment standard. Long intervals between checks miss pressure injuries, ischemia, and entrapment events that the monitoring schedule is designed to catch promptly. Option b is incorrect because square knots can tighten under tension and prevent quick removal during an emergency. The standard requires a quick-release knot such as a half-bow so staff can free the limb immediately when needed. Option c is incorrect because side rails move when the bed is adjusted and could pull on the restraint, injuring the wrist. Restraints are always tied to the bed frame to prevent traction injury during routine repositioning of the client.

Correct Answer: Report suspicion to CPS

Suspected child abuse is a mandatory report regardless of certainty. Nurses are mandated reporters under state law and must notify Child Protective Services based on reasonable suspicion, with good-faith reporting protections built into the statute for clinicians. Option b is incorrect because discussing concerns with a potentially abusive parent before reporting can endanger the child and tip off the suspected abuser. The standard sequence is to notify CPS first and let trained investigators interview the family. Option c is incorrect because discharging without reporting fails the duty to report and exposes the child to ongoing harm. Documentation supports the report but does not replace the legal obligation to notify the agency promptly today. Option d is incorrect because counseling referrals address relational stress but bypass the mandatory reporting law. Counseling can be added later, yet the immediate legal duty is to file the CPS report based on the observed findings now.

Correct Answer: Positive-pressure room with HEPA filtration

Neutropenic precautions protect the client from environmental pathogens using a positive-pressure room with HEPA filtration. Air flows outward from the room so unfiltered hallway air, microbes, and spores cannot enter the immunocompromised client's environment safely. Option a is incorrect because negative pressure is the opposite of what protective isolation requires. Negative pressure pulls air into the room to keep airborne pathogens inside, which would expose a neutropenic client rather than protect them from outside organisms. Option b is incorrect because fresh flowers carry bacteria and fungal spores in the water and on the petals. Neutropenic precautions exclude fresh flowers and produce because the client cannot fight off opportunistic environmental organisms during deep immunosuppression today. Option c is incorrect because standing water in humidifiers and vases supports microbial growth and aerosolization. The protective protocol eliminates standing water in the room t

Correct Answer: Contact provider for clarification

An unclear or unsafe order must be clarified with the prescribing provider before any administration. The nurse is legally accountable for following an unsafe order, even when written, so direct clarification is the required next step before bedside action. Option b is incorrect because guessing at intent on a high-alert medication places the client at serious risk. The do-not-use abbreviation already invites misinterpretation, and acting on assumption could deliver a tenfold error or wrong drug entirely today. Option c is incorrect because the pharmacist may verify dose ranges but cannot rewrite the prescriber's order. Clarification must come from the provider who placed the order so that any change is documented and authorized through the appropriate channel. Option d is incorrect because administering a partial dose is itself an unauthorized modification of the order. Modifying a dose without provider direction constitutes practicing outside scope and does not resolve the under

Correct Answer: Notify security; activate Code Pink

Any unknown person carrying a concealing bag near a newborn unit raises concern for infant abduction. The Code Pink protocol triggers immediate lockdown, search of exits, and security mobilization before the suspected abductor can leave the building safely. Option a is incorrect because returning to routine work allows a potential abductor to escape with a newborn. Documentation later cannot recover a missing infant, so timely activation of the established code is the priority response right now today. Option c is incorrect because a single nurse approaching a suspected abductor introduces personal risk and may signal the abductor to flee. The standard protocol routes confrontation through trained security personnel during the lockdown response on the unit. Option d is incorrect because paging after report leaves a critical window during which exits remain open. Code Pink relies on immediate facility-wide lockdown to detect and intercept the suspected abductor before they reach an exit

Correct Answer: Dispose glass in sharps container

Broken glass from medication ampules is treated as a sharp and disposed of in a rigid, puncture-proof, labeled sharps container per OSHA bloodborne pathogen standards. Placing the glass safely prevents needlestick-equivalent injuries during cleanup procedures on the unit. Option a is incorrect because recapping is generally avoided and is not the issue at hand, which is the loose glass shard. The one-handed scoop technique is reserved for unavoidable needle recapping, not for broken ampules on the medication cart. Option b is incorrect because contaminated broken glass placed in regular trash can pierce bags and injure environmental services workers. Sharps disposal is the only safe receptacle for these pieces, irrespective of their small size and apparent harmless appearance. Option d is incorrect because wiping with a thin paper towel risks driving glass shards into the gloved palm. The shard must be removed mechanically with tongs or a stiff scoop before any wet cleanup of the medic

Correct Answer: Have client sign AMA; educate

A competent client may leave against medical advice after signing the AMA form, which documents informed refusal of continued care. The nurse provides written discharge instructions, follow-up information, and notifies the provider, but cannot physically restrain the client. Option a is incorrect because physically blocking a competent client constitutes false imprisonment, an intentional tort. Security cannot restrain a person who has capacity and has chosen to leave, even when leaving carries medical risk for the pneumonia. Option b is incorrect because telling the client they must wait imposes a delay the client has not consented to. The nurse can offer to call the provider, but cannot demand the client remain against their clearly expressed wishes today. Option c is incorrect because refusing the AMA form does not prevent departure and removes the documentation that protects the team. The signed form records that the client received and understood risk information before walking ou

Correct Answer: Discuss HIV privately in hallway

Sensitive information such as HIV status, psychiatric history, or social concerns is discussed away from unauthorized visitors. Bedside report continues for non-sensitive content after the private exchange so that the client's HIPAA rights are protected during the change of shift. Option a is incorrect because skipping all clinical content defeats the purpose of bedside report and leaves the oncoming nurse without information needed for safe care. The exchange continues for routine items while sensitive content is handled separately and privately. Option b is incorrect because the presence of a family member does not constitute authorization to receive PHI. Sharing HIV status without the client's documented permission breaches HIPAA regardless of how close the visiting family member appears to be. Option d is incorrect because dismissing the visitor abruptly damages the therapeutic relationship and may alarm the client. The standard practice is to ask politely with an explana

Correct Answer: Wash hands around wound contact

At home, routine handwashing before and after wound contact, covering the wound with a clean dressing, and avoiding shared personal items such as towels and razors are sufficient. Family members do not need full contact isolation outside the healthcare setting. Option b is incorrect because hospital-style contact isolation is unnecessary at home for routine household contacts. Home transmission risk is managed with hand hygiene, dressing intactness, and laundry hygiene rather than full gown-and-glove protocols at the kitchen table. Option c is incorrect because gowns add no protection in a non-clinical environment with healthy household members. The recommended home measures emphasize hand hygiene and not sharing personal items rather than donning healthcare PPE around the living room. Option d is incorrect because separating the niece is not part of standard home MRSA management. School-age children with intact skin and good hand hygiene face minimal risk and do not require relocation

Correct Answer: Honor request; inform care team

The client controls disclosure of personal health information under HIPAA. The nurse honors the request, documents the client's preference, and informs the care team so that no one inadvertently shares the diagnosis with family members without proper consent. Option a is incorrect because disclosing PHI to family without the client's authorization is a breach of HIPAA. Acting in what the nurse considers the family's interest does not override the client's right to control who learns of the diagnosis. Option c is incorrect because redirecting the family to the provider still places the diagnosis at risk of disclosure without consent. The provider faces the same HIPAA constraint and would only confirm details that the client has expressly authorized today. Option d is incorrect because documentation is appropriate but notifying family contradicts the client's expressed wishes. The documentation should record the client's preference for privacy so all staff a

Correct Answer: Bag at point of use

Standard precautions require bagging soiled linen at the point of use without shaking to prevent aerosolization of pathogens and contamination of the environment. The bag is then transported in a closed, leak-resistant manner to the laundry chute downstairs. Option a is incorrect because shaking linen releases organisms into the air and onto surrounding surfaces. The recommended practice keeps linen folded inward and bagged immediately, even when small items such as caps or tubing may be inside the folds. Option b is incorrect because pressing the linen against the gown spreads contamination from linen to uniform. The standard keeps soiled linen away from clothing and instructs the nurse to hold the bag open rather than the linen close. Option c is incorrect because transporting unbagged linen through a public corridor exposes other clients and staff to organisms. Linen must be contained in the room before any movement through shared hospital spaces such as the corridor outside the doo

Correct Answer: Breathing thirty-two per minute, weak pulse

Under START triage, a respiratory rate above thirty or absent radial pulse marks a victim as immediate or red. A weak pulse with rapid breathing signals shock and demands evacuation ahead of others to receive lifesaving stabilization quickly. Option a is incorrect because a victim who can walk and follow commands belongs in the green or minor category by START rules. Walking wounded gather at a holding area, leaving the immediate transport corridor open for red tag casualties. Option b is incorrect because the absence of breathing after airway repositioning marks the victim as black or expectant in the START algorithm. In a mass casualty event, resources flow to salvageable casualties rather than to this victim. Option d is incorrect because alert refusing victims with minor cuts differ sharply from the unstable casualties prioritized red. Refusing care does not bump someone up the triage hierarchy, and the team continues toward those who cannot self-evacuate.

Correct Answer: Place copy in the chart

Advance directive documents should be filed in the chart on admission so the team can act on them quickly if capacity is later lost. While the client retains capacity, decision-making remains with the client and the document stays in reserve. Option b is incorrect because the daughter does not sign consents while the client has capacity. The proxy authority activates only when the client cannot make decisions, and substituting the proxy now would override the client's autonomous voice immediately. Option c is incorrect because waiting to file the document until capacity is questioned creates a delay during a future emergency. Filing on admission ensures the directive is available immediately when needed without searching for the original document later. Option d is incorrect because filing an advance directive is a routine nursing task that does not require social work consultation. Social work supports complex psychosocial situations, but standard chart placement of the directive

Correct Answer: Sterile dressing change for wound

Sterile dressing changes for stable surgical wounds fit within the LPN scope of practice. The RN performs initial teaching and assessment, while the UAP handles routine vital signs, making the dressing change the best LPN-only task on this assignment today. Option a is incorrect because initial admission assessment is reserved for the RN. The full assessment requires the RN's clinical judgment to develop a nursing diagnosis and care plan, neither of which can be delegated to the LPN appropriately. Option b is incorrect because initial teaching belongs to the RN, with the LPN reinforcing teaching the RN began. New diabetes regimen instruction is a first-time teaching event and must therefore originate with the RN rather than the LPN. Option c is incorrect because routine vital signs on a stable client are appropriate for the UAP. Assigning this to the LPN would underuse the LPN's scope when other tasks on the assignment require licensed skills and clinical knowledge.

Correct Answer: Root cause analysis with five whys

Root cause analysis is a structured retrospective process used after a sentinel event to identify systemic contributors. The five whys technique asks why repeatedly to move beyond the immediate cause to the underlying systems issue that allowed the event. Option b is incorrect because FMEA is a prospective tool used to predict failure points before a new process launches. The current scenario is retrospective and triggered by an event that already occurred, which is the defining feature of RCA. Option c is incorrect because RCA explicitly focuses on systems rather than individuals. A performance evaluation of staff would assign blame and undermine the just culture environment that supports honest reporting and root cause discovery across the team safely. Option d is incorrect because coaching is reserved for at-risk behavior under the just culture framework, not for a structured sentinel event investigation. The team is performing analysis, which is a distinct activity from coaching in

Correct Answer: Provider face-to-face within one hour

Behavioral restraints require a licensed independent practitioner to perform a face-to-face evaluation within one hour of initiation. The nurse may begin restraint in an emergency but the LIP must evaluate the client and confirm the order in person. Option a is incorrect because behavioral restraint orders are renewed at much shorter intervals than twenty-four hours. Adult behavioral restraints renew every four hours, with shorter intervals for pediatric ages, and require ongoing reassessment with each renewal cycle. Option b is incorrect because PRN restraint orders are never permitted. Each restraint episode requires a new order with a fresh evaluation, which prevents indefinite or anticipatory use of restraint as a routine convenience on the unit. Option c is incorrect because skipping the face-to-face evaluation violates federal regulations and Joint Commission standards. The in-person evaluation by the LIP is the safeguard that distinguishes behavioral restraint from routine medic

Correct Answer: Forward-facing harness, back seat

A four-year-old weighing forty pounds belongs in a forward-facing five-point harness car seat in the back seat. The child transitions to a booster around the upper limits of the harness seat and remains in the back seat until age thirteen. Option b is incorrect because booster seats belong in the back seat for any child under thirteen and the typical transition begins around age four to five at the harness limit. Front-seat placement exposes a young child to airbag injury. Option c is incorrect because rear-facing seats are recommended until at least age two, and most four-year-olds have outgrown the rear-facing weight limit. A forty-pound four-year-old fits a forward-facing harness rather than a rear-facing convertible seat. Option d is incorrect because standard seat belts do not fit small bodies safely and ride up onto the abdomen. Children typically need boosters until they reach four feet nine inches in height or roughly eight to twelve years old.

Correct Answer: Gloves, goggles, gown, mask

Doffing starts with the most contaminated items and includes hand hygiene between steps. Gloves come off first, then goggles, gown, and mask last because the mask protected against airborne droplets that could be inhaled during the doffing process. Option a is incorrect because removing the mask before the gloves and gown contaminates the face area. The mask must remain in place during the messy removal of gloves and gown to shield from any aerosolized particles released during doffing. Option c is incorrect because removing the gown before the gloves transfers contamination from the gown to the bare hands. Gloves come off first so the gown can be peeled away without ungloved skin touching the contaminated outer surface. Option d is incorrect because hand hygiene is performed between steps and at the end of doffing, but this option assumes none is needed. Skipping hand hygiene leaves microorganisms transferred during PPE removal on the hands, defeating the sequence.