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HESI A2 / NURS347 CRITICAL THINKING
QUESTIONS & ANSWERS – 100% VERIFIED
COMPLETE STUDY GUIDE | 150 QUESTIONS |
DETAILED RATIONALES
TABLE OF CONTENTS
| Section | Topic | Questions |
|---------|-------|-----------|
| 1 | Prioritization (ABCs, Maslow, Safety) | 25 |
| 2 | Delegation & Supervision (LPN, UAP scope) | 15 |
| 3 | Nursing Process (ADPIE application) | 20 |
| 4 | Ethical & Legal Decision-Making | 15 |
| 5 | Clinical Judgment & Situational Reasoning | 25 |
| 6 | Patient Safety & Error Prevention | 15 |
| 7 | Communication & Conflict Resolution | 10 |
| 8 | Pharmacology & Medication Safety | 15 |
| 9 | Emergency & Rapid Response | 10 |
| 10 | NGN Case Studies (Standalone items) | 10 |
| **TOTAL** | | **150** |
---
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## SECTION 1 – PRIORITIZATION (ABCs, Maslow, Safety) (25
Questions)
**1. A nurse receives report on four clients. Which client should be
assessed first?**
- A) Client with pneumonia, SpO2 88% on 2L oxygen
- B) Client with diabetes, blood glucose 180 mg/dL
- C) Client with dementia who is wandering
- D) Client with a scheduled dressing change
** Correct Answer: A – SpO2 88% on oxygen**
**Rationale:** ABCs (Airway, Breathing, Circulation) first. Hypoxia
(SpO2 <90%) is a breathing priority. Increase oxygen, reassess. Stable
chronic conditions (glucose 180) and wandering are lower priority.
**2. A nurse is caring for a client post-operative day 1 after abdominal
surgery. Which finding requires immediate intervention?**
- A) Temperature 38.0°C (100.4°F)
- B) Heart rate 100 bpm
- C) Respiratory rate 10 breaths/min
- D) Blood pressure 130/80 mmHg
** Correct Answer: C – Respiratory rate 10 breaths/min**
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**Rationale:** Respiratory rate <12 (bradypnea) indicates potential
respiratory depression (opioids, anesthesia). Airway/breathing priority.
Mild fever and tachycardia are expected post-op.
**3. A client with chest pain and shortness of breath is admitted. Which
action should the nurse take first?**
- A) Obtain a 12-lead ECG
- B) Administer oxygen at 2 L nasal cannula
- C) Start an IV line
- D) Draw cardiac enzymes
** Correct Answer: B – Administer oxygen**
**Rationale:** ABCs: breathing first. Oxygen improves oxygenation.
ECG and IV are important but not first. Oxygen can be applied while
obtaining other assessments.
**4. A client is receiving a blood transfusion and reports chills and back
pain. What is the priority action?**
- A) Slow the infusion rate
- B) Stop the transfusion
- C) Notify the provider
- D) Administer acetaminophen
** Correct Answer: B – Stop the transfusion**
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**Rationale:** Suspect hemolytic transfusion reaction. Stop transfusion
immediately, keep IV line open with saline, notify provider.
Airway/breathing/circulation first.
**5. A nurse is caring for four clients. Which client is at highest risk for
falls?**
- A) Client with pneumonia, alert and oriented
- B) Client post-stroke with hemiparesis and confusion
- C) Client with a broken arm, ambulatory
- D) Client with a urinary catheter
** Correct Answer: B – Post-stroke with confusion and
hemiparesis**
**Rationale:** Fall risk factors: confusion, impaired mobility, history of
falls, medications (sedatives). Use Morse scale. Confusion + weakness =
highest risk.
**6. A client with a new tracheostomy becomes diaphoretic, heart rate
130, and SpO2 drops to 82%. What is the priority?**
- A) Call a rapid response
- B) Suction the tracheostomy
- C) Increase oxygen
- D) Deflate the cuff
** Correct Answer: B – Suction the tracheostomy**
HESI A2 / NURS347 CRITICAL THINKING
QUESTIONS & ANSWERS – 100% VERIFIED
COMPLETE STUDY GUIDE | 150 QUESTIONS |
DETAILED RATIONALES
TABLE OF CONTENTS
| Section | Topic | Questions |
|---------|-------|-----------|
| 1 | Prioritization (ABCs, Maslow, Safety) | 25 |
| 2 | Delegation & Supervision (LPN, UAP scope) | 15 |
| 3 | Nursing Process (ADPIE application) | 20 |
| 4 | Ethical & Legal Decision-Making | 15 |
| 5 | Clinical Judgment & Situational Reasoning | 25 |
| 6 | Patient Safety & Error Prevention | 15 |
| 7 | Communication & Conflict Resolution | 10 |
| 8 | Pharmacology & Medication Safety | 15 |
| 9 | Emergency & Rapid Response | 10 |
| 10 | NGN Case Studies (Standalone items) | 10 |
| **TOTAL** | | **150** |
---
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## SECTION 1 – PRIORITIZATION (ABCs, Maslow, Safety) (25
Questions)
**1. A nurse receives report on four clients. Which client should be
assessed first?**
- A) Client with pneumonia, SpO2 88% on 2L oxygen
- B) Client with diabetes, blood glucose 180 mg/dL
- C) Client with dementia who is wandering
- D) Client with a scheduled dressing change
** Correct Answer: A – SpO2 88% on oxygen**
**Rationale:** ABCs (Airway, Breathing, Circulation) first. Hypoxia
(SpO2 <90%) is a breathing priority. Increase oxygen, reassess. Stable
chronic conditions (glucose 180) and wandering are lower priority.
**2. A nurse is caring for a client post-operative day 1 after abdominal
surgery. Which finding requires immediate intervention?**
- A) Temperature 38.0°C (100.4°F)
- B) Heart rate 100 bpm
- C) Respiratory rate 10 breaths/min
- D) Blood pressure 130/80 mmHg
** Correct Answer: C – Respiratory rate 10 breaths/min**
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**Rationale:** Respiratory rate <12 (bradypnea) indicates potential
respiratory depression (opioids, anesthesia). Airway/breathing priority.
Mild fever and tachycardia are expected post-op.
**3. A client with chest pain and shortness of breath is admitted. Which
action should the nurse take first?**
- A) Obtain a 12-lead ECG
- B) Administer oxygen at 2 L nasal cannula
- C) Start an IV line
- D) Draw cardiac enzymes
** Correct Answer: B – Administer oxygen**
**Rationale:** ABCs: breathing first. Oxygen improves oxygenation.
ECG and IV are important but not first. Oxygen can be applied while
obtaining other assessments.
**4. A client is receiving a blood transfusion and reports chills and back
pain. What is the priority action?**
- A) Slow the infusion rate
- B) Stop the transfusion
- C) Notify the provider
- D) Administer acetaminophen
** Correct Answer: B – Stop the transfusion**
, 4|Page
**Rationale:** Suspect hemolytic transfusion reaction. Stop transfusion
immediately, keep IV line open with saline, notify provider.
Airway/breathing/circulation first.
**5. A nurse is caring for four clients. Which client is at highest risk for
falls?**
- A) Client with pneumonia, alert and oriented
- B) Client post-stroke with hemiparesis and confusion
- C) Client with a broken arm, ambulatory
- D) Client with a urinary catheter
** Correct Answer: B – Post-stroke with confusion and
hemiparesis**
**Rationale:** Fall risk factors: confusion, impaired mobility, history of
falls, medications (sedatives). Use Morse scale. Confusion + weakness =
highest risk.
**6. A client with a new tracheostomy becomes diaphoretic, heart rate
130, and SpO2 drops to 82%. What is the priority?**
- A) Call a rapid response
- B) Suction the tracheostomy
- C) Increase oxygen
- D) Deflate the cuff
** Correct Answer: B – Suction the tracheostomy**
