HESI A2 CRITICAL THINKING 2026
PRACTICE TEST QUESTIONS WITH EXPERT
VERIFIED SOLUTIONS GRADED A+
⩥ 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.
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.
⩥ 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.
Answer: Rationale
Correct -1. The nurse should always praise the child for attempts at
cooperation even if the child did not accomplish what the nurse asked.
⩥ 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%.
Answer: Rationale
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.
,⩥ 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).
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; therefore, this medication does not have to be adminis-
tered first.
, ⩥ 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.
Answer: Rationale
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.
PRACTICE TEST QUESTIONS WITH EXPERT
VERIFIED SOLUTIONS GRADED A+
⩥ 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.
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.
⩥ 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.
Answer: Rationale
Correct -1. The nurse should always praise the child for attempts at
cooperation even if the child did not accomplish what the nurse asked.
⩥ 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%.
Answer: Rationale
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.
,⩥ 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).
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; therefore, this medication does not have to be adminis-
tered first.
, ⩥ 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.
Answer: Rationale
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.
