NURSING MISC: HESI A2 - CRITICAL THINKING EXAM WITH RATIONALE/2023.Qualified,

NURSING MISC: HESI A2 - CRITICAL THINKING EXAM WITH RATIONALE/2023.Qualified, 1. The nurse is caring for clients on the pediatric medical unit. Which client should the nurseassess first? 1. The child diagnosed with type 1 diabetes who has a blood glucose levelof 180 mg/dL. 2. The child diagnosed with pneumonia who is coughing and has a temperature of100°F. 3. The child diagnosed with gastroenteritis who has a potassium (K+) levelof 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 lifethreatening; therefore, this child should be assessed first. 5. The nurse has received the a.m. shift report for clients on a pediatric unit. Which medicationshould the nurse administer first? 1. The third dose of the aminoglycoside antibiotic to the child diagnosed withmethicillin-resistant Staphylococcus aureus (MRSA). 2. The IVP steroid methylprednisolone (Solu-Medrol) to the child diagnosed withasthma. 2 3. The sliding scale insulin to the child diagnosed with type 1 diabetes mellitus. 4. The stimulant methylphenidate (Ritalin) to a child diagnosed with attentiondeficit-hyperactivity disorder (ADHD). Rationale Correct - 3-Sliding scale insulin is ordered ac, which is before meals; therefore, this medication must beadministered 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. Whichinterventions 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. Determineunresponsiveness. 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 takennot 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, preferablywith 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 of30:2. The nurse is working in the emergency department (ED) of a children's medical center. Whichclient 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-oldschool-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. Rational