HESI A2 - CRITICAL THINKING EXAM
QUESTIONS AND ANSWERS
1. The nurse is working in the emergency department (ED) of a children's medical
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center. Which client should the nurse assess first?
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1. The 1-month-old infant who has developed colic and is crying.
vb vb vb vb vb vb vb vb vb vb
2. The 2-year-old toddler who was bitten by another child at the day-
vb vb vb vb vb vb vb vb vb vb vb vb
care center. 3. The 6-year-old school-
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age child who was hit by a car while riding a bicycle.
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4. The 14-year-
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old adolescent whose mother suspects her child is sexually active. - ANSWERS--
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Rationale vb
Correct - 3- vb vb
The child hit by a car should be assessed first because he or she may have life-
vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb
threatening injuries that must be assessed and treated promptly.
vb vb vb vb vb vb vb vb vb
1. In an interview, the nurse may find it necessary to take notes to aid his or her
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memory later. Which statement is true regarding note-taking?
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A) Note-
vb
taking may impede the nurse's observation of the patient's nonverbal behaviors.
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B) Note-
vb
taking allows the patient to continue at his or her own pace as the nurse records w
vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb
hat is said.
vb vb
C) Note- vb
taking allows the nurse to shift attention away from the patient, resulting in an incr
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eased comfort level. vb vb
D) Note- vb
taking allows the nurse to break eye contact with the patient, which may increase
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his or her level of comfort. - ANSWERS--A) Note-
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taking may impede the nurse's observation of the patient's nonverbal behaviors.
vb vb vb vb vb vb vb vb vb vb
Page: 31 Some use of history forms and note-
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taking may be unavoidable. But be aware that note-
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taking during the interview has disadvantages. It breaks eye contact too often, and
vb vb vb vb vb vb vb vb vb vb vb vb v
bit shifts attention away from the patient, which diminishes his or her sense of impo
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rtance. It also may interrupt the patient's narrative flow, and it impedes the observa
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tion of the patient's nonverbal behavior.
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2. The 8-year-old client diagnosed with a vaso-
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occlusive sickle cell crisis is complaining of a severe headache. Which intervention
vb vb vb vb vb vb vb vb vb vb vb v
bshould the nurse implement first?
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1. Administer 6 L of oxygen via nasal cannula.
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2. Assess the client's neurological status.
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3. Administer a narcotic analgesic by intravenous push (IVP). 4. Increase the client
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's intravenous (IV) rate. - ANSWERS--Rationale
vb vb vb vb vb vb
,Correct - 2- vb vb
Because the client is complaining of a headache, the nurse should first rule out cer
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ebrovascular accident (CVA) by assess- vb vb vb vb
ing the client's neurological status and then determine whether it is a headache th
vb vb vb vb vb vb vb vb vb vb vb vb vb vb
at can be treated with medication.
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2. During an interview, the nurse states, "You mentioned shortness of breath. Tell
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me more about that." Which verbal skill is used with this statement?
vb vb vb vb vb vb vb vb vb vb vb
A) vb Reflection
B) vb Facilitation
C) vb Direct question vb
D) vb Open-ended question - ANSWERS--D) Open-ended question vb vb vb vb vb
Page: 32 The open- vb vb vb
ended question asks for narrative information. It states the topic to be discussed b
vb vb vb vb vb vb vb vb vb vb vb vb vb
ut only in general terms. The nurse should use it to begin the interview, to introduc
vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb
e a new section of questions, and whenever the person introduces a new topic.
vb vb vb vb vb vb vb vb vb vb vb vb vb
3. The 6-year-
vb vb
old client who has undergone abdominal surgery is attempting to make a pinwheel
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spin by blowing on it with the nurse's assistance. The child starts crying because t
b vb vb vb vb vb vb vb vb vb vb vb vb vb vb
he pinwheel won't spin. Which action should the nurse implement first?
vb vb vb vb vb vb vb vb vb vb
1. Praise the child for the attempt to make the pinwheel spin.
vb vb vb vb vb vb vb vb vb vb vb
2. Notify the respiratory therapist to implement incentive spirometry. 3. Encourage t
vb vb vb vb vb vb vb vb vb vb vb
he child to turn from side to side and cough.
vb vb vb vb vb vb vb vb vb
4. Demonstrate how to make the pinwheel spin by blowing on it. - ANSWERS--
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Rationale vb
Correct - vb
1. The nurse should always praise the child for attempts at cooperation even if the
vb vb vb vb vb vb vb vb vb vb vb vb vb vb v
child did not accomplish what the nurse asked.
b vb vb vb vb vb vb vb
3. A nurse is taking complete health histories on all of the patients attending a well
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ness workshop. On the history form, one of the written questions asks, "You don't
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smoke, drink, or take drugs, do you?" This question is an example of:
vb vb vb vb vb vb vb vb vb vb vb vb
A) vb talking too much. vb vb
B) vb using confrontation. vb
C) vb using biased or leading questions.
vb vb vb vb
D) vb using blunt language to deal with distasteful topics. - ANSWERS--
vb vb vb vb vb vb vb vb vb
C) vb using biased or leading questions.
vb vb vb vb
Page: 36 This is an example of using leading or biased questions. Asking, "You do
vb vb vb vb vb vb vb vb vb vb vb vb vb vb
n't smoke, do you?" implies that one answer is "better" than another. If the person
vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb
wants to please someone, he or she is either forced to answer in a way correspon
vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb
ding to their implied values or is made to feel guilty when admitting the other answ
vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb
er.
,4. The nurse is caring for clients on the pediatric medical unit. Which client should
vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb
the nurse assess first?
vb vb vb
1. The child diagnosed with type 1 diabetes who has a blood glucose level
vb vb vb vb vb vb vb vb vb vb vb vb vb
of 180 mg/dL.
vb vb
2. The child diagnosed with pneumonia who is coughing and has a temperature of
vb vb vb vb vb vb vb vb vb vb vb vb vb
100°F.
3. The child diagnosed with gastroenteritis who has a potassium (K+) level
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of 3.9 mEq/L.
vb vb
4. The child diagnosed with cystic fibrosis who has a pulse oximeter reading of 90
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%. - ANSWERS--Rationale
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Correct - vb
4. A pulse oximeter reading of less than 93% is significant and indicates hypoxia,
vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb
which is life threatening; therefore, this child should be assessed first.
vb vb vb vb vb vb vb vb vb vb
4. During an interview, a parent of a hospitalized child is sitting in an open position
vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb
. As the interviewer begins to discuss his son's treatment, however, he suddenly cr
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osses his arms against his chest and crosses his legs. This would suggest that the
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parent is:
vb vb
A) vb just changing positions.
vb vb
B) vb more comfortable in this position.
vb vb vb vb
C) vb tired and needs a break from the interview.
vb vb vb vb vb vb vb
D) vb uncomfortable talking about his son's treatment. - ANSWERS-- vb vb vb vb vb vb vb
D) vb uncomfortable talking about his son's treatment. vb vb vb vb vb
Page: 37 Note the person's position. An open position with the extension of large
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muscle groups shows relaxation, physical comfort, and a willingness to share infor
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mation. A closed position with the arms and legs crossed tends to look defensive a
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nd anxious. Note any change in posture. If a person in a relaxed position suddenly
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tenses, it suggests possible discomfort with the new topic.
b vb vb vb vb vb vb vb vb
5. The nurse has received the a.m. shift report for clients on a pediatric unit. Whic
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h medication should the nurse administer first?
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1. The third dose of the aminoglycoside antibiotic to the child diagnosed with
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methicillin-resistant Staphylococcus aureus (MRSA). vb vb vb
2. The IVP steroid methylprednisolone (Solu-Medrol) to the child diagnosed with
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asthma.
3. The sliding scale insulin to the child diagnosed with type 1 diabetes mellitus.
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4. The stimulant methylphenidate (Ritalin) to a child diagnosed with attention
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deficit-hyperactivity disorder (ADHD). - ANSWERS--Rationale vb vb vb vb vb
Correct - 3- vb vb
Sliding scale insulin is ordered ac, which is before meals; therefore, this medicatio
vb vb vb vb vb vb vb vb vb vb vb vb
n must be administered first after receiving the a.m. shift report.
vb vb vb vb vb vb vb vb vb vb
4-Routine medications have a 1- vb vb vb vb
hour leeway before and after the scheduled time; therefore, this medication does n
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ot have to be adminis- tered first.
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, 5. The nurse is interviewing a patient who has a hearing impairment. What techniq
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ues would be most beneficial in communicating with this patient?
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A) Determine the communication method he prefers.
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B) Avoid using facial and hand gestures because most hearing-
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impaired people find this degrading. vb vb vb vb
C) Request a sign language interpreter before meeting with him to help facilitate th
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e communication.
vb
D) Speak loudly and with exaggerated facial movement when talking with him bec
vb vb vb vb vb vb vb vb vb vb vb vb
ause this helps with lip reading. - ANSWERS--
vb vb vb vb vb vb vb
A) Determine the communication method he prefers.
vb vb vb vb vb vb
Pages: 40- vb
41 The nurse should ask the deaf person the preferred way to communicate—
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by signing, lip reading, or writing. If the person prefers lip reading, then the nurse s
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hould be sure to face him or her squarely and have good lighting on the nurse's fa
vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb
ce. The nurse should not exaggerate lip movements because this distorts words. S
vb vb vb vb vb vb vb vb vb vb vb vb
imilarly, shouting distorts the reception of a hearing aid the person may wear. The
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nurse should speak slowly and should supplement his or her voice with appropriat
vb vb vb vb vb vb vb vb vb vb vb vb
e hand gestures or pantomime.
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6. The nurse enters the client's room and realizes the 9-month-
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old infant is not breath- ing. Which interventions should the nurse implement?
vb vb vb vb vb vb vb vb vb vb vb
vbPrioritize the nurse's actions from first (1) to last (5).
vb vb vb vb vb vb vb vb vb
1. Perform cardiac compression 30:2.
vb vb vb vb
2. Check the infant's brachial pulse. 3. Administer two puffs to the infant. 4. Deter
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mine unresponsiveness.
vb
5. Open the infant's airway. - ANSWERS--Rationale
vb vb vb vb vb vb vb
Correct Answer: 4, 5, 3, 2, 1 vb vb vb vb vb vb
4. The nurse must first determine the
vb vb vb vb vb vb
infant's responsiveness by thumping the
vb vb vb vb
baby's feet. vb
5. The nurse should then open the child's
vb vb vb vb vb vb vb
airway using the head-tilt chin-lift tech-
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vbnique, with care taken not to hyperextend the neck. Then the nurse should look, li
vb vb vb vb vb vb vb vb vb vb vb vb vb vb
sten, and feel for respirations.
vb vb vb vb
3. The nurse then administers quick puffs of air while covering the child's mouth a
vb vb vb vb vb vb vb vb vb vb vb vb vb vb
nd nose, preferably with a rescue mask.
vb vb vb vb vb vb
2. The nurse should determine whether the infant has a pulse by checking the bra
vb vb vb vb vb vb vb vb vb vb vb vb vb vb
chial artery. vb
1. If the infant has no pulse, the nurse should begin chest compressions using two
vb vb vb vb vb vb vb vb vb vb vb vb vb vb v
bfingers at a rate of 30:2. vb vb vb vb vb
6. The nurse is performing a health interview on a patient who has a language bar
vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb
rier, and no interpreter is available. Which is the best example of an appropriate q
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uestion for the nurse to ask in this situation?
vb vb vb vb vb vb vb vb
A) "Do you take medicine?"
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B) "Do you sterilize the bottles?"
vb vb vb vb vb
C) "Do you have nausea and vomiting?"
vb vb vb vb vb vb
QUESTIONS AND ANSWERS
1. The nurse is working in the emergency department (ED) of a children's medical
vb vb vb vb vb vb vb vb vb vb vb vb vb vb
center. Which client should the nurse assess first?
vb vb vb vb vb vb vb
1. The 1-month-old infant who has developed colic and is crying.
vb vb vb vb vb vb vb vb vb vb
2. The 2-year-old toddler who was bitten by another child at the day-
vb vb vb vb vb vb vb vb vb vb vb vb
care center. 3. The 6-year-old school-
vb vb vb vb vb
age child who was hit by a car while riding a bicycle.
vb vb vb vb vb vb vb vb vb vb vb
4. The 14-year-
vb vb
old adolescent whose mother suspects her child is sexually active. - ANSWERS--
vb vb vb vb vb vb vb vb vb vb vb
Rationale vb
Correct - 3- vb vb
The child hit by a car should be assessed first because he or she may have life-
vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb
threatening injuries that must be assessed and treated promptly.
vb vb vb vb vb vb vb vb vb
1. In an interview, the nurse may find it necessary to take notes to aid his or her
vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb
memory later. Which statement is true regarding note-taking?
vb vb vb vb vb vb vb vb
A) Note-
vb
taking may impede the nurse's observation of the patient's nonverbal behaviors.
vb vb vb vb vb vb vb vb vb vb
B) Note-
vb
taking allows the patient to continue at his or her own pace as the nurse records w
vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb
hat is said.
vb vb
C) Note- vb
taking allows the nurse to shift attention away from the patient, resulting in an incr
vb vb vb vb vb vb vb vb vb vb vb vb vb vb
eased comfort level. vb vb
D) Note- vb
taking allows the nurse to break eye contact with the patient, which may increase
vb vb vb vb vb vb vb vb vb vb vb vb vb vb
his or her level of comfort. - ANSWERS--A) Note-
vb vb vb vb vb vb vb vb
taking may impede the nurse's observation of the patient's nonverbal behaviors.
vb vb vb vb vb vb vb vb vb vb
Page: 31 Some use of history forms and note-
vb vb vb vb vb vb vb vb
taking may be unavoidable. But be aware that note-
vb vb vb vb vb vb vb vb
taking during the interview has disadvantages. It breaks eye contact too often, and
vb vb vb vb vb vb vb vb vb vb vb vb v
bit shifts attention away from the patient, which diminishes his or her sense of impo
vb vb vb vb vb vb vb vb vb vb vb vb vb vb
rtance. It also may interrupt the patient's narrative flow, and it impedes the observa
vb vb vb vb vb vb vb vb vb vb vb vb vb
tion of the patient's nonverbal behavior.
vb vb vb vb vb
2. The 8-year-old client diagnosed with a vaso-
vb vb vb vb vb vb vb
occlusive sickle cell crisis is complaining of a severe headache. Which intervention
vb vb vb vb vb vb vb vb vb vb vb v
bshould the nurse implement first?
vb vb vb vb
1. Administer 6 L of oxygen via nasal cannula.
vb vb vb vb vb vb vb vb
2. Assess the client's neurological status.
vb vb vb vb vb
3. Administer a narcotic analgesic by intravenous push (IVP). 4. Increase the client
vb vb vb vb vb vb vb vb vb vb vb vb
's intravenous (IV) rate. - ANSWERS--Rationale
vb vb vb vb vb vb
,Correct - 2- vb vb
Because the client is complaining of a headache, the nurse should first rule out cer
vb vb vb vb vb vb vb vb vb vb vb vb vb vb
ebrovascular accident (CVA) by assess- vb vb vb vb
ing the client's neurological status and then determine whether it is a headache th
vb vb vb vb vb vb vb vb vb vb vb vb vb vb
at can be treated with medication.
vb vb vb vb vb
2. During an interview, the nurse states, "You mentioned shortness of breath. Tell
vb vb vb vb vb vb vb vb vb vb vb vb vb
me more about that." Which verbal skill is used with this statement?
vb vb vb vb vb vb vb vb vb vb vb
A) vb Reflection
B) vb Facilitation
C) vb Direct question vb
D) vb Open-ended question - ANSWERS--D) Open-ended question vb vb vb vb vb
Page: 32 The open- vb vb vb
ended question asks for narrative information. It states the topic to be discussed b
vb vb vb vb vb vb vb vb vb vb vb vb vb
ut only in general terms. The nurse should use it to begin the interview, to introduc
vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb
e a new section of questions, and whenever the person introduces a new topic.
vb vb vb vb vb vb vb vb vb vb vb vb vb
3. The 6-year-
vb vb
old client who has undergone abdominal surgery is attempting to make a pinwheel
vb vb vb vb vb vb vb vb vb vb vb vb v
spin by blowing on it with the nurse's assistance. The child starts crying because t
b vb vb vb vb vb vb vb vb vb vb vb vb vb vb
he pinwheel won't spin. Which action should the nurse implement first?
vb vb vb vb vb vb vb vb vb vb
1. Praise the child for the attempt to make the pinwheel spin.
vb vb vb vb vb vb vb vb vb vb vb
2. Notify the respiratory therapist to implement incentive spirometry. 3. Encourage t
vb vb vb vb vb vb vb vb vb vb vb
he child to turn from side to side and cough.
vb vb vb vb vb vb vb vb vb
4. Demonstrate how to make the pinwheel spin by blowing on it. - ANSWERS--
vb vb vb vb vb vb vb vb vb vb vb vb vb
Rationale vb
Correct - vb
1. The nurse should always praise the child for attempts at cooperation even if the
vb vb vb vb vb vb vb vb vb vb vb vb vb vb v
child did not accomplish what the nurse asked.
b vb vb vb vb vb vb vb
3. A nurse is taking complete health histories on all of the patients attending a well
vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb
ness workshop. On the history form, one of the written questions asks, "You don't
vb vb vb vb vb vb vb vb vb vb vb vb vb vb
smoke, drink, or take drugs, do you?" This question is an example of:
vb vb vb vb vb vb vb vb vb vb vb vb
A) vb talking too much. vb vb
B) vb using confrontation. vb
C) vb using biased or leading questions.
vb vb vb vb
D) vb using blunt language to deal with distasteful topics. - ANSWERS--
vb vb vb vb vb vb vb vb vb
C) vb using biased or leading questions.
vb vb vb vb
Page: 36 This is an example of using leading or biased questions. Asking, "You do
vb vb vb vb vb vb vb vb vb vb vb vb vb vb
n't smoke, do you?" implies that one answer is "better" than another. If the person
vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb
wants to please someone, he or she is either forced to answer in a way correspon
vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb
ding to their implied values or is made to feel guilty when admitting the other answ
vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb
er.
,4. The nurse is caring for clients on the pediatric medical unit. Which client should
vb vb vb vb vb vb vb vb vb vb vb vb vb vb vb
the nurse assess first?
vb vb vb
1. The child diagnosed with type 1 diabetes who has a blood glucose level
vb vb vb vb vb vb vb vb vb vb vb vb vb
of 180 mg/dL.
vb vb
2. The child diagnosed with pneumonia who is coughing and has a temperature of
vb vb vb vb vb vb vb vb vb vb vb vb vb
100°F.
3. The child diagnosed with gastroenteritis who has a potassium (K+) level
vb vb vb vb vb vb vb vb vb vb vb
of 3.9 mEq/L.
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4. The child diagnosed with cystic fibrosis who has a pulse oximeter reading of 90
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%. - ANSWERS--Rationale
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Correct - vb
4. A pulse oximeter reading of less than 93% is significant and indicates hypoxia,
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which is life threatening; therefore, this child should be assessed first.
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4. During an interview, a parent of a hospitalized child is sitting in an open position
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. As the interviewer begins to discuss his son's treatment, however, he suddenly cr
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osses his arms against his chest and crosses his legs. This would suggest that the
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parent is:
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A) vb just changing positions.
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B) vb more comfortable in this position.
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C) vb tired and needs a break from the interview.
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D) vb uncomfortable talking about his son's treatment. - ANSWERS-- vb vb vb vb vb vb vb
D) vb uncomfortable talking about his son's treatment. vb vb vb vb vb
Page: 37 Note the person's position. An open position with the extension of large
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muscle groups shows relaxation, physical comfort, and a willingness to share infor
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mation. A closed position with the arms and legs crossed tends to look defensive a
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nd anxious. Note any change in posture. If a person in a relaxed position suddenly
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tenses, it suggests possible discomfort with the new topic.
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5. The nurse has received the a.m. shift report for clients on a pediatric unit. Whic
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h medication should the nurse administer first?
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1. The third dose of the aminoglycoside antibiotic to the child diagnosed with
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methicillin-resistant Staphylococcus aureus (MRSA). vb vb vb
2. The IVP steroid methylprednisolone (Solu-Medrol) to the child diagnosed with
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asthma.
3. The sliding scale insulin to the child diagnosed with type 1 diabetes mellitus.
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4. The stimulant methylphenidate (Ritalin) to a child diagnosed with attention
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deficit-hyperactivity disorder (ADHD). - ANSWERS--Rationale vb vb vb vb vb
Correct - 3- vb vb
Sliding scale insulin is ordered ac, which is before meals; therefore, this medicatio
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n must be administered first after receiving the a.m. shift report.
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4-Routine medications have a 1- vb vb vb vb
hour leeway before and after the scheduled time; therefore, this medication does n
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ot have to be adminis- tered first.
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, 5. The nurse is interviewing a patient who has a hearing impairment. What techniq
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ues would be most beneficial in communicating with this patient?
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A) Determine the communication method he prefers.
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B) Avoid using facial and hand gestures because most hearing-
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impaired people find this degrading. vb vb vb vb
C) Request a sign language interpreter before meeting with him to help facilitate th
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e communication.
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D) Speak loudly and with exaggerated facial movement when talking with him bec
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ause this helps with lip reading. - ANSWERS--
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A) Determine the communication method he prefers.
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Pages: 40- vb
41 The nurse should ask the deaf person the preferred way to communicate—
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by signing, lip reading, or writing. If the person prefers lip reading, then the nurse s
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hould be sure to face him or her squarely and have good lighting on the nurse's fa
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ce. The nurse should not exaggerate lip movements because this distorts words. S
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imilarly, shouting distorts the reception of a hearing aid the person may wear. The
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nurse should speak slowly and should supplement his or her voice with appropriat
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e hand gestures or pantomime.
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6. The nurse enters the client's room and realizes the 9-month-
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old infant is not breath- ing. Which interventions should the nurse implement?
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vbPrioritize the nurse's actions from first (1) to last (5).
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1. Perform cardiac compression 30:2.
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2. Check the infant's brachial pulse. 3. Administer two puffs to the infant. 4. Deter
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mine unresponsiveness.
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5. Open the infant's airway. - ANSWERS--Rationale
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Correct Answer: 4, 5, 3, 2, 1 vb vb vb vb vb vb
4. The nurse must first determine the
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infant's responsiveness by thumping the
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baby's feet. vb
5. The nurse should then open the child's
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airway using the head-tilt chin-lift tech-
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vbnique, with care taken not to hyperextend the neck. Then the nurse should look, li
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sten, and feel for respirations.
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3. The nurse then administers quick puffs of air while covering the child's mouth a
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nd nose, preferably with a rescue mask.
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2. The nurse should determine whether the infant has a pulse by checking the bra
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chial artery. vb
1. If the infant has no pulse, the nurse should begin chest compressions using two
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bfingers at a rate of 30:2. vb vb vb vb vb
6. The nurse is performing a health interview on a patient who has a language bar
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rier, and no interpreter is available. Which is the best example of an appropriate q
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uestion for the nurse to ask in this situation?
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A) "Do you take medicine?"
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B) "Do you sterilize the bottles?"
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C) "Do you have nausea and vomiting?"
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