1. The nurse is working in the emergency department (ED) of a children's medical center. Which client should the nurse assess first?
1. The 1-month-old infant who has developed colic and is crying.
2. The 2-year-old toddler who was bitten by another child at the day-care center. 3. The 6...
administer a narcotic analgesic by intravenous push ivp 4 increase the clients intravenous iv rate
because the client is complaining of a headache
the nurse should first rule out cerebrova
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HESI A2-CRITICAL THINKING RATIONALE
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,1. The nurse is working in the emergency department (ED) of a children's medical center. Which
client should the nurse assess first?
1. The 1-month-old infant who has developed colic and is crying.
2. The 2-year-old toddler who was bitten by another child at the day-care center. 3.
The 6-year-old school-age child who was hit by a car while riding a bicycle.
4. The 14-year-old adolescent whose mother suspects her child is sexually
active. Rationale
Correct - 3-The child hit by a car should be assessed first because he or she may have life-
threatening injuries that must be assessed and treated promptly.
2. The 8-year-old client diagnosed with a vaso-occlusive sickle cell crisis is complaining of a
severe headache. Which intervention should the nurse implement first?
1. Administer 6 L of oxygen via nasal
cannula. 2. Assess the client's
neurological status.
3. Administer a narcotic analgesic by intravenous push (IVP). 4. Increase the client's
intravenous (IV) rate.
Rationale
Correct - 2-Because the client is complaining of a headache, the nurse should first rule out
cerebrovascular accident (CVA) by assess- ing the client's neurological status and then
determine whether it is a headache that can be treated with medication.
3. The 6-year-old client who has undergone abdominal surgery is attempting to make a pinwheel
spin by blowing on it with the nurse's assistance. The child starts crying because the pinwheel
won't spin. Which action should the nurse implement first?
1. Praise the child for the attempt to make the pinwheel spin.
2. Notify the respiratory therapist to implement incentive spirometry. 3. Encourage the
child to turn from side to side and cough.
4. Demonstrate how to make the pinwheel spin by blowing
on it. Rationale
Correct -1. The nurse should always praise the child for attempts at cooperation even if the
child did not accomplish what the nurse asked.
4. The nurse is caring for clients on the pediatric medical unit. Which client should the nurse
assess first?
1. The child diagnosed with type 1 diabetes who has a blood
glucose level of 180 mg/dL.
2. The child diagnosed with pneumonia who is coughing and has a
temperature of 100°F.
3. The child diagnosed with gastroenteritis who has a potassium
(K+) level of 3.9 mEq/L.
4. The child diagnosed with cystic fibrosis who has a pulse oximeter
reading of 90%. Rationale
Correct - 4. A pulse oximeter reading of less than 93% is significant and indicates hypoxia,
which is life threatening; therefore, this child should be assessed first.
5. The nurse has received the a.m. shift report for clients on a pediatric unit. Which
medication should the nurse administer first?
1. The third dose of the aminoglycoside antibiotic to the child
diagnosed with methicillin-resistant Staphylococcus aureus
(MRSA).
2. The IVP steroid methylprednisolone (Solu-Medrol) to the child
2
,diagnosed with asthma.
3
, 3. The sliding scale insulin to the child diagnosed with type 1 diabetes mellitus.
4. The stimulant methylphenidate (Ritalin) to a child diagnosed
with attention deficit-hyperactivity disorder (ADHD).
Rationale
Correct - 3-Sliding scale insulin is ordered ac, which is before meals; therefore, this
medication must be administered first after receiving the a.m. shift report.
4-Routine medications have a 1-hour leeway before and after the scheduled time; therefore,
this medication does not have to be adminis- tered first.
6. The nurse enters the client's room and realizes the 9-month-old infant is not breath- ing. Which
interventions should the nurse implement? Prioritize the nurse's actions from first (1) to last (5).
1. Perform cardiac compression 30:2.
2. Check the infant's brachial pulse. 3. Administer two puffs to the infant. 4.
Determine unresponsiveness.
5. Open the infant's
airway. Rationale
Correct Answer: 4, 5, 3, 2, 1
4. The nurse must first determine the infant's responsiveness by thumping the baby's feet.
5. The nurse should then open the child's airway using the head-tilt chin-lift tech- nique,
with care taken not to hyperextend the neck. Then the nurse should look, listen, and feel
for respirations.
3. The nurse then administers quick puffs of air while covering the child's mouth and nose,
preferably with a rescue mask.
2. The nurse should determine whether the infant has a pulse by checking the brachial
artery.
1. If the infant has no pulse, the nurse should begin chest compressions using two fingers
at a rate of 30:2.
7. The 3-year-old client has been admitted to the pediatric unit. Which task should the nurse
instruct the unlicensed assistive personnel (UAP) to perform first?
1. Orient the parents and child to the room.
2. Obtain an admission kit for the child.
3. Post the child's height and weight at the HOB. 4. Provide the child with a
meal tray. Rationale
Correct - 1.The first intervention after the child is ad- mitted to the unit is to orient the
parents and child to the room, the call system, and the hospital rules, such as not leaving
the child alone in the room.
8. The clinic nurse is preparing to administer an intramuscular (IM) injection to the 2-year-
old toddler. Which intervention should the nurse implement first?
1. Immobilize the child's leg.
2. Explain the procedure to the child.
3. Cleanse the area with an alcohol swab. 4. Administer the medication
in the thigh. Rationale
Correct - 2-The nurse must explain any procedure in words the child can understand. It does
not matter how old the child is.
9. The nurse is writing a care plan for the 5-year-old child diagnosed with gastroenteritis.
Which client problem is priority?
1. Imbalanced nutrition.
2. Fluid volume deficit.
3. Knowledge deficit. 4. Risk for
infection. Rationale
Correct - 2-The child diagnosed with gastroenteritis is at high risk for hypovolemic shock
resulting from vomiting and diarrhea; therefore, maintaining fluid and elec- trolyte
homeostasis is priority.
10. Which data would warrant immediate intervention from the pediatric nurse? 1.
4
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