HESI A2 CRITICAL THINKING 2021
1. The Patient: A 65-year- old male.
The Situation: The family brings the patient to the emergency room because he just took an entire bottle of pills.
The Question: What action should the nurse take first? Correct Answer: Answer - Determine the patient's level of...
HESI A2 CRITICAL THINKING 2021
1. The Patient: A 65-year- old male.
The Situation: The family brings the patient to the emergency room because he just took an entire bottle
of pills.
The Question: What action should the nurse take first? Correct Answer: Answer - Determine the
patient's level of consciousness.
1. The Patient: An 80 year-old male who has used continuous oxygen for the past three years.
The Situation: While making a home visit, the wife tells the nurse that her husband was doing well on 2
litres of oxygen per minute until late last night when he developed severe shortness of breath on the
way to the bathroom.
The Question: What action should the nurse take first? Correct Answer: Answer - Assess the patient's
oxygen saturation by pulse oximeter.
1. The Patient: A 41-year-old male.
The Situation: The patient is complaining of severe stomach pain and states that he has been "vomiting
all the time."
The Question: What should the nurse do first? Correct Answer: Answer - Administer a prescribed pain
medication.
1. The Patient: The wife of a wealthy owner of the town's bank.
The Situation: The patient and her husband arrive on the unit. While orienting the patient to the hospital
room, the nurse notices that the patient has placed a large amount of cash and some expensive earrings
in the drawer of the bedside table.
The Question: What is the best action for the nurse to take? Correct Answer: Answer - Advise the
patient to have her husband take the items home when he leaves.
1. The Patient: A 45-year-old female who is 5' 2" tall, weighs 200 pounds, and has smoked since age 21.
The Situation: The patient comes to the clinic with a complaint of "leg pain."
The Question: It is most important for the nurse to obtain information about which previous
occurrence? Correct Answer: Answer - A previous blood clot in the leg.
1. The Patient: A 61-year-old female.
The Situation: The patient has a fever of unknown origin. The nurse administered a fever-reducing
medication 30 minutes ago. At this time there has been no decrease in the patient's fever.
The Question: What action would be best for the nurse to take? Correct Answer: Answer - Sponge the
patient with cool water.
1. The Patient: A 70-year-old male who is relatively healthy.
The Situation: A liquid mediation is prescribed for this patient.
The Question: Prior to administering the prescribed medication, what intervention has the highest
priority? Correct Answer: Answer - Determine if the patient is allergic to the medication.
1. The Patient: A fifty-eight-year-old female.
The Situation: While the nurse is offering the patient her morning medications, she tells the nurse that
she does not recall ever taking a pill that was pink-colored.
, The Question: What should the nurse do in response to this patient's comment? Correct Answer:
Answer - Withhold the mediation until the patient's prescription is verify.
1. The Patients:
1. A 63-year-old with a burn on the left lower leg who is complaining of pain.
2. A 45-year-old with pneumonia, complaining of shortness of breath.
3. A 31-year-old with abdominal pain who has just vomited blood.
4. An 88-year-old who has right-sided paralysis and wants to be helped to the bathroom immediately.
The Situation: The nurse is caring for these patients.
The Question: Who should the nurse see first? Correct Answer: Answer - The 45-years old with
pneumonia and shortness of breath.
1. The Patients:
1. A 13-year-old female with a kidney infection who reports that there is "lots of blood" in her urine.
2. An 18-year-old male with acute alcohol poisoning who is seeing "bugs on the walls."
3. A 21-year-old female with inflammatory bowel disease who has soaked a dressing three hours after
surgery.
4. A 25-year old male who is sobbing in his room after being told that he has testicular cancer.
The Situation: The nurse is caring for these four patients.
The Question: Who should the nurse see first? Correct Answer: Answer - The 21-years old who is three
hours postoperative and has a soaked dressing.
1. The Patients:
1. A 42-year-old with diabetes who is blind and is asking to get up and moved to a chair.
2. An 88-year-old with lower body paralysis who wants to be turned in bed.
3. A 17-year-old with asthma who smokes and has been in the bathroom for 30 minutes.
4. A 55-year-old with cardiac disease who tells the nurse, "Get the TV fixed or I am leaving this place."
The Situation: The nurse is caring for these four patients.
The Question: Which patient should the nurse see first? Correct Answer: Answer - The 17-year old with
asthma who may be smoking in the bathroom.
1. The Patient: An elderly female accompanied by her middle-aged son.
The Situation: The patient is being discharged after 15-day stay on the medical unit, and the son offers
the nurse a box of candy as a gesture of thanks for caring for his mother.
The Question: What should the nurse do in response to the offer of this gift? Correct Answer: Answer -
Sincerely thank the son, and share the candy with all staff member on the unit.
1. The Patient: A 25-year-old female who has smoked since age 12.
The Situation: The patient is complaining of "skipped heart beats."
The Question: Which instruction is most important for the nurse to provide this patient? Correct
Answer: Answer - Call for assistance if she feels weak or dizzy when getting out of bed.
1. The Patient: A frail 88-year-old male who has recently become slightly confused.
The Situation: The nurse is making a home visit and assesses the safety features of the home
environment.
The Question: Which suggestion would be most important for the nurse to provide the family? Correct
Answer: Answer - Eliminate any throw rugs from floor.
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