HESI E2 HESI Exit Exam - Set 1 - Part 3

Correct Answer: Wash puncture with soap and water

The first action after a needlestick is to wash the exposed area with soap and water or flush mucous membranes with saline. Notification of the supervisor, source testing, and post-exposure prophylaxis follow this immediate decontamination at the exposure point. Option a is incorrect because antiretroviral prophylaxis is started ideally within one to two hours of exposure, but only after washing the site. Beginning therapy before decontamination skips the simplest reduction of viral inoculum at the puncture wound itself. Option b is incorrect because source patient testing requires consent and laboratory time. Pursuing the source test before washing the wound leaves contaminated material on the skin during the wait for results and consent from the source individual involved. Option d is incorrect because supervisor notification is a necessary later step but does not address the contaminated site. Reporting before washing leaves the puncture untreated during the documentation conversati

Correct Answer: Throw rugs in the hallway

Throw rugs are a leading cause of falls in older adults because they slip, fold, and trip the foot. Removing them or securing them with non-slip backing is the most immediate intervention since falls are the top injury cause. Option b is incorrect because unsorted medications create risks for dosing errors but do not produce the immediate physical trip hazard of a loose rug. Medication organization is addressed during the visit as a separate teaching priority later. Option c is incorrect because missing grab bars increase risk during transfers but their installation takes time to arrange. The throw rugs can be removed immediately during the visit, and that removal produces fall risk reduction the same day. Option d is incorrect because dim lighting near stairs is dangerous but is also a longer-term modification involving night lights or wiring. Improving stair lighting is added to the plan, while rug removal happens before the nurse leaves today.

Correct Answer: Notify provider if questions remain

The RN's role in consent is to witness the signature, verify understanding, and notify the provider if the client has questions. The provider remains responsible for explaining the procedure, risks, benefits, and alternatives before consent is considered legally valid. Option a is incorrect because re-explaining the procedure exceeds the RN's role in informed consent unless the procedure is a nursing intervention. Detailed re-explanation of a provider procedure must come from the provider rather than the witnessing nurse. Option b is incorrect because a competent client signs their own consent and a spouse cannot substitute. Spousal signature on a competent adult's behalf misrepresents authorization and invalidates the consent process for the medication being administered later this morning. Option d is incorrect because witnessing a signature with unresolved client questions ignores the comprehension element of informed consent. The nurse pauses the process and notifies

Correct Answer: Two clients with active MRSA

Cohorting is acceptable when both clients carry the same active organism, such as two clients with MRSA. Mixing different organisms or pairing a contagious client with a non-infected client risks cross-transmission and breaks isolation principles for the unit. Option b is incorrect because active tuberculosis requires a single-occupancy airborne infection isolation room with negative pressure. Pairing an actively contagious TB client with any roommate violates airborne precaution requirements and endangers the roommate severely with active disease. Option c is incorrect because a neutropenic client requires a single-occupancy positive-pressure room to protect against environmental pathogens. Sharing a room exposes the immunocompromised client to organisms shed by the roommate during daily activities and casual contact. Option d is incorrect because C. difficile is transmitted through spores that survive on surfaces and require contact precautions. Sharing a room with a postoperative cl

Correct Answer: Assess client and tubing

Alarm response begins with assessing the client and the equipment together. The nurse checks the line for kinks, the bag for emptiness, and the access site for infiltration so the underlying cause of the alarm is identified and corrected. Option a is incorrect because silencing the alarm without identifying the cause leaves an occlusion that may indicate infiltration or kinking. Continuing to round while the alarm is silenced risks fluid leakage or a clotted line over the next minutes. Option b is incorrect because documentation precedes neither assessment nor intervention. Charting the alarm without acting on it leaves the client in the situation that produced the alarm, with no resolution of the actual problem occurring at the bedside. Option c is incorrect because resetting and resuming the rate without checking the cause may push fluid against an occlusion. Pressure against a kinked line, clotted catheter, or infiltrated site can extend tissue damage and rupture the tubing soon.

Correct Answer: Verify client, procedure, site

The Universal Protocol time-out confirms correct client, correct procedure, correct site, correct side, and correct position immediately before incision. Allergies, antibiotic timing, and availability of imaging and implants are also verified during the structured pause before the surgical incision. Option a is incorrect because billing and insurance review belongs to the registration process, not the surgical time-out. The time-out is a final safety check focused on confirming the right person, procedure, and site, with everyone listening attentively. Option c is incorrect because discharge instructions are reviewed after the procedure and do not belong in the time-out. The time-out is a brief pre-incision pause for safety verification, not for postoperative planning at this moment before the case. Option d is incorrect because reading the consent aloud is not part of the time-out structure. Consent verification is one element but the time-out is a structured confirmation of identifie

Correct Answer: U for insulin units

The abbreviation U for unit is on the ISMP do-not-use list because it is easily mistaken for a zero or a four, leading to tenfold or fortyfold dose errors. The provider must clarify by spelling out unit instead. Option a is incorrect because PO for by mouth remains a standard, approved abbreviation. It has not been identified as confusing or unsafe and is widely used in medication orders without leading to dose or route errors on any list. Option b is incorrect because BID is approved for twice-daily dosing and is not on the do-not-use list. Confusion arises with QD or QOD for daily and every-other-day frequencies, not with BID for twice daily on a routine list today. Option d is incorrect because PRN is an accepted abbreviation for as-needed administration. The abbreviation is not on the ISMP do-not-use list and does not cause the dosing confusion that the abbreviation U produces with handwritten insulin orders specifically.

Correct Answer: Intervene; verify authorization first

HIPAA disclosures to family members require either prior client authorization or the client's verbal permission. The nurse intervenes to verify whether the caller appears on the approved list before any clinical information is shared by phone from the unit. Option a is incorrect because family relationship alone does not authorize PHI disclosure under HIPAA. Sharing the diagnosis without verifying authorization places the facility at legal risk and breaches the client's right to control personal health information from outside callers. Option b is incorrect because the room number itself is a direct identifier and links the caller to the client's presence in the hospital. Confirming the room number to an unauthorized caller still constitutes a HIPAA disclosure of protected information. Option c is incorrect because deferring the call does not resolve the authorization question. The same disclosure issue would arise at any callback time, and clients deserve a process that

Correct Answer: One point for benzodiazepine use

On the Hendrich II Fall Risk Model, any administered benzodiazepine adds one point to the total score. The clinician adds points from other categories such as confusion, depression, elimination, and the get-up-and-go test to obtain the cumulative score. Option a is incorrect because four points on the Hendrich II is assigned for confusion, disorientation, or impulsivity rather than for benzodiazepine use. Confusing these categories inflates the total score and may trigger unnecessary high-risk interventions for the client. Option b is incorrect because the tool does not list three points for any single category. Selecting this value reflects a misunderstanding of the model and could lead to scoring errors that misclassify the client's actual fall risk level today. Option d is incorrect because five points is the threshold for high risk on the Hendrich II rather than a value for benzodiazepine use. Conflating the threshold with a single category value distorts the entire scoring ap

Correct Answer: Schedule as first case

The latex-allergic client is scheduled as the first case of the day to minimize airborne latex particle exposure from prior cases. The room is set up with latex-free supplies, a latex-allergy sign is posted, and the wristband alerts the team. Option a is incorrect because scheduling last exposes the client to a full day's worth of accumulated airborne latex particles. The standard practice for latex-allergy protection minimizes prior latex use in the room rather than maximizing it before the case. Option c is incorrect because latex gloves are exactly what must be avoided. Latex-free alternatives such as nitrile, vinyl, or neoprene must replace latex gloves throughout the entire perioperative period to prevent a reaction from beginning during the case. Option d is incorrect because a chart sticker alone does not protect the client during equipment selection. Active substitution of latex-free supplies, scheduling adjustments, and visible room signage are all required for genuine la