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HESI A2 - Critical Thinking 2024/2025 already graded A+
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HESI A2 - Critical Thinking 2024/2025 already graded A+
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HESI A2 - Critical Thinking1. 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. -
ANSRationale
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.
1. In an interview, the nurse may find it necessary to take notes to aid his or her memory later.
Which statement is true regarding note-taking?
A) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors.
B) Note-taking allows the patient to continue at his or her own pace as the nurse records what is
said.
C) Note-taking allows the nurse to shift attention away from the patient, resulting in an increased
comfort level.
D) Note-taking allows the nurse to break eye contact with the patient, which may increase his or
her level of comfort. - ANSA) Note-taking may impede the nurse's observation of the patient's
nonverbal behaviors.
Page: 31 Some use of history forms and note-taking may be unavoidable. But be aware that
note-taking during the interview has disadvantages. It breaks eye contact too often, and it shifts
attention away from the patient, which diminishes his or her sense of importance. It also may
interrupt the patient's narrative flow, and it impedes the observation of the patient's nonverbal
behavior.
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. - ANSRationale
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.
,2. During an interview, the nurse states, "You mentioned shortness of breath. Tell me more
about that." Which verbal skill is used with this statement?
A) Reflection
B) Facilitation
C) Direct question
D) Open-ended question - ANSD) Open-ended question
Page: 32 The open-ended question asks for narrative information. It states the topic to be
discussed but only in general terms. The nurse should use it to begin the interview, to introduce
a new section of questions, and whenever the person introduces a new topic.
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. - ANSRationale
Correct -1. The nurse should always praise the child for attempts at cooperation even if the child
did not accomplish what the nurse asked.
3. A nurse is taking complete health histories on all of the patients attending a wellness
workshop. On the history form, one of the written questions asks, "You don't smoke, drink, or
take drugs, do you?" This question is an example of:
A) talking too much.
B) using confrontation.
C) using biased or leading questions.
D) using blunt language to deal with distasteful topics. - ANSC) using biased or leading
questions.
Page: 36 This is an example of using leading or biased questions. Asking, "You don't smoke, do
you?" implies that one answer is "better" than another. If the person wants to please someone,
he or she is either forced to answer in a way corresponding to their implied values or is made to
feel guilty when admitting the other answer.
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%. -
ANSRationale
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.
4. During an interview, a parent of a hospitalized child is sitting in an open position. As the
interviewer begins to discuss his son's treatment, however, he suddenly crosses his arms
against his chest and crosses his legs. This would suggest that the parent is:
A) just changing positions.
B) more comfortable in this position.
C) tired and needs a break from the interview.
D) uncomfortable talking about his son's treatment. - ANSD) uncomfortable talking about his
son's treatment.
Page: 37 Note the person's position. An open position with the extension of large muscle groups
shows relaxation, physical comfort, and a willingness to share information. A closed position
with the arms and legs crossed tends to look defensive and anxious. Note any change in
posture. If a person in a relaxed position suddenly tenses, it suggests possible discomfort with
the new topic.
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 diagnosed with
asthma.
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). - ANSRationale
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.
5. The nurse is interviewing a patient who has a hearing impairment. What techniques would be
most beneficial in communicating with this patient?
A) Determine the communication method he prefers.
, B) Avoid using facial and hand gestures because most hearing-impaired people find this
degrading.
C) Request a sign language interpreter before meeting with him to help facilitate the
communication.
D) Speak loudly and with exaggerated facial movement when talking with him because this
helps with lip reading. - ANSA) Determine the communication method he prefers.
Pages: 40-41 The nurse should ask the deaf person the preferred way to communicate—by
signing, lip reading, or writing. If the person prefers lip reading, then the nurse should be sure to
face him or her squarely and have good lighting on the nurse's face. The nurse should not
exaggerate lip movements because this distorts words. Similarly, shouting distorts the reception
of a hearing aid the person may wear. The nurse should speak slowly and should supplement
his or her voice with appropriate hand gestures or pantomime.
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. - ANSRationale
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.
6. The nurse is performing a health interview on a patient who has a language barrier, and no
interpreter is available. Which is the best example of an appropriate question for the nurse to
ask in this situation?
A) "Do you take medicine?"
B) "Do you sterilize the bottles?"
C) "Do you have nausea and vomiting?"
D) "You have been taking your medicine, haven't you?" - ANSA) "Do you take medicine?"
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