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HESI A2 - Critical Thinking Exam With All Questions And 100% Correct Answers (A+) Latest Update
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HESI A2 - Critical Thinking Exam With All Questions And100% Correct Answers (A+) Latest Update
1. The nurse is working in the 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. -
ANWER 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.
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) In note-taking, the nurse might not attend to the patient's non-verbal behaviors.
B) The patient can continue at a comfortable pace while the nurse documents what was
said.
C) Note-taking allows the nurse to divert attention from the patient, which increases
comfort level.
D) Note-taking allows the nurse to break eye contact with the patient, which may
increase his or her level of comfort. - ANSWER A) 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 not be avoidable. However,
note that note-taking during the interview has drawbacks. The eye contact is broken too
many times, and attention is diverted away from the patient, which reduces his or her
sense of significance. It can also interrupt the patient's stream of talk, and it hinders
observation of the patient's non-verbal behavior.
,2. The 8-year-old client who is experiencing a vaso-occlusive sickle cell crisis is
complaining of a severe headache. Which intervention should the nurse institute first?
1. Administer 6 L of oxygen via nasal cannula.
2. Perform a neurologic assessment of the client.
3. Administer a narcotic analgesic by IVP.
4. Increase the rate of the client's IV. - ANSWER 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.
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 - ANSWER D) 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 create a
spinning pinwheel with the assistance of the nurse by blowing on the pinwheel. The child
starts to cry because the pinwheel does not spin. What is the first action by the nurse?
1. Reinforce the child for attempting to make the pinwheel spin.
2. Order the respiratory therapist to begin incentive spirometry. 3. Place the child in a
position to turn to side to side and cough.
4. Describe to the child through play how to blow on the pinwheel so that it will spin. -
ANSWER Rationale
,Correct-1. The nurse should always reinforce a child when an attempt at cooperation
has been made even if the child did not do what the nurse requested.
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. - ANSWER C) using biased or
leading questions.
Page: 36 This is a leading or biased question example. To ask, "You don't smoke, do
you?" signals that one response 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 with a diagnosis of cystic fibrosis whose pulse oximeter reading is 90%. -
ANSWER Rationale
Correct - 4. A less than 93% pulse oximeter reading is significant and indicates hypoxia,
, which is a life-threatening condition; therefore, this child should be assessed first.
4. A parent of a hospitalized child is sitting in an open position during an interview.
However, as the interviewer begins to discuss his son's treatment, he suddenly crosses
his arms across his chest and crosses his legs. This would indicate that the parent is:
A) simply changing positions.
B) more comfortable in this position.
C) tired and needs a break from the interview.
D) uneasy discussing the treatment of his son. - ANSWER D) uncomfortable talking
about his son's treatment.
Page: 37 Note the position of a person. An open position with the extension of large
muscle groups shows relaxation, physical comfort, and a readiness to share
information. A closed position with 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. In what
order should the nurse administer these medications?
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 medication methylphenidate (Ritalin) is prescribed to a child for attention
deficit-hyperactivity disorder. - ANSWER 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;
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