HESI A2 Critical Thinking
1. The nurse is working in the emergency department (ED) of a children's medical center. Whichclient should
the nurse assess first?
A. The 1-month-old infant who has developed colic and is crying.
B. The 2-year-old toddler who was bitten by another child at the day-care center.
C. The 6-year-oldschool-age child who was hit by a car while riding a bicycle.
D. The 14-year-old adolescent whose mother suspects her child is sexually active.
Rationale
ANS : C -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.
2. The 8-year-old client diagnosed with a vaso-occlusive sickle cell crisis is complaining of asevere headache.
Which intervention should the nurse implement first?
A. Administer 6 L of oxygen via nasal cannula.
B. Assess the client's neurological status.
C. Administer a narcotic analgesic by intravenous push (IVP).
D. Increase the client's intravenous (IV)rate.
Rationale
ANS : B-Because the client is complaining of a headache, the nurse should first rule out cerebrovascular accident
(CVA) by assessing the client's neurological status and then determinewhether 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 pinwheelspin 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?
A. Praise the child for the attempt to make the pinwheel spin.
B. Notify the respiratory therapist to implement incentive spirometry.
C. Encourage the child to turn fromside to side and cough.
D. Demonstrate how to make the pinwheel spin by blowing on it.
Rationale
ANS –A. The nurse should always praise the child for attempts at cooperation even if the child did notaccomplish
what the nurse asked.
4. The nurse is caring for clients on the pediatric medical unit. Which client should the nurseassess first?
A. The child diagnosed with type 1 diabetes who has a blood glucose levelof 180
mg/dL.
B. The child diagnosed with pneumonia who is coughing and has a temperature of100°F.
C. The child diagnosed with gastroenteritis who has a potassium (K+) levelof 3.9
mEq/L.
D. The child diagnosed with cystic fibrosis who has a pulse oximeter reading of 90%.
Rationale
ANS - D. A pulse oximeter reading of less than 93% is significant and indicates hypoxia, which is lifethreatening;
therefore, this child should be assessed first.
1
,5. The nurse has received the a.m. shift report for clients on a pediatric unit. Which medicationshould the
nurse administer first?
A. The third dose of the aminoglycoside antibiotic to the child diagnosed with
methicillin-resistant Staphylococcus aureus (MRSA).
B. The IVP steroid methylprednisolone (Solu-Medrol) to the child diagnosed with
asthma.
2
, C. The sliding scale insulin to the child diagnosed with type 1 diabetes mellitus.
D. The stimulant methylphenidate (Ritalin) to a child diagnosed with attention
deficit-hyperactivity disorder (ADHD).
Rationale
ANS : C -Sliding scale insulin is ordered ac, which is before meals; therefore, this medication must beadministered
first after receiving the a.m. shift report.
4-Routine medications have a 1-hour leeway before and after the scheduled time; therefore, thismedication does not
have to be administered 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).
A. Perform cardiac compression 30:2.
B. Check the infant's brachial pulse.
C. Administer two puffs to the infant.
D. Determineunresponsiveness.
E. Open the infant's airway.
Rationale
ANS Answer: D, E, C, B, A
D.The nurse must first determine the infant's responsiveness by thumping the baby's feet.
E. The nurse should then open the child's airway using the head-tilt chin-lift tech- nique, with care takennot to
hyperextend the neck. Then the nurse should look, listen, and feel for respirations.
C. The nurse then administers quick puffs of air while covering the child's mouth and nose, preferablywith a
rescue mask.
B. The nurse should determine whether the infant has a pulse by checking the brachial artery.
A. If the infant has no pulse, the nurse should begin chest compressions using two fingers at a rate of30:2.
7. The 3-year-old client has been admitted to the pediatric unit. Which task should the nurseinstruct the
unlicensed assistive personnel (UAP) to perform first?
A. Orient the parents and child to the room.
B. Obtain an admission kit for the child.
C. Post the child's height and weight at the HOB.
D. Provide the child with a meal tray.
Rationale
ANS – A .The first intervention after the child is admitted to the unit is to orient the parents and child to the room,
the call system, and the hospital rules, such as not leaving the child alone in the room.
8. The clinic nurse is preparing to administer an intramuscular (IM) injection to the 2-year-old toddler.Which
intervention should the nurse implement first?
A. Immobilize the child's leg.
B. Explain the procedure to the child.
C. Cleanse the area with an alcohol swab.
D. Administer the medication in the thigh.
Rationale
ANS - B-The nurse must explain any procedure in words the child can understand. It does not matterhow old the
child is.
9. The nurse is writing a care plan for the 5-year-old child diagnosed with gastroenteritis. Which client problem is
priority?
3
, A. Imbalanced nutrition.
B. Fluid volume deficit.
C. Knowledge deficit.
D. Risk for infection.
Rationale
ANS - B-The child diagnosed with gastroenteritis is at high risk for hypovolemic shock resulting fromvomiting and
diarrhea; therefore, maintaining fluid and electrolyte homeostasis is priority.
10. Which data would warrant immediate intervention from the pediatric nurse?
A . Proteinuria for thechild diagnosed with nephrotic syndrome.
B.Petechiae for the child diagnosed with leukemia.
C. Drooling for a child diagnosed with acute epiglottitis.
D. Elevated temperature in a child diagnosed with otitis media.
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1. The nurse is working in the emergency department (ED) of a children's medical center. Whichclient should
the nurse assess first?
A. The 1-month-old infant who has developed colic and is crying.
B. The 2-year-old toddler who was bitten by another child at the day-care center.
C. The 6-year-oldschool-age child who was hit by a car while riding a bicycle.
D. The 14-year-old adolescent whose mother suspects her child is sexually active.
Rationale
ANS : C -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.
2. The 8-year-old client diagnosed with a vaso-occlusive sickle cell crisis is complaining of asevere headache.
Which intervention should the nurse implement first?
A. Administer 6 L of oxygen via nasal cannula.
B. Assess the client's neurological status.
C. Administer a narcotic analgesic by intravenous push (IVP).
D. Increase the client's intravenous (IV)rate.
Rationale
ANS : B-Because the client is complaining of a headache, the nurse should first rule out cerebrovascular accident
(CVA) by assessing the client's neurological status and then determinewhether 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 pinwheelspin 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?
A. Praise the child for the attempt to make the pinwheel spin.
B. Notify the respiratory therapist to implement incentive spirometry.
C. Encourage the child to turn fromside to side and cough.
D. Demonstrate how to make the pinwheel spin by blowing on it.
Rationale
ANS –A. The nurse should always praise the child for attempts at cooperation even if the child did notaccomplish
what the nurse asked.
4. The nurse is caring for clients on the pediatric medical unit. Which client should the nurseassess first?
A. The child diagnosed with type 1 diabetes who has a blood glucose levelof 180
mg/dL.
B. The child diagnosed with pneumonia who is coughing and has a temperature of100°F.
C. The child diagnosed with gastroenteritis who has a potassium (K+) levelof 3.9
mEq/L.
D. The child diagnosed with cystic fibrosis who has a pulse oximeter reading of 90%.
Rationale
ANS - D. A pulse oximeter reading of less than 93% is significant and indicates hypoxia, which is lifethreatening;
therefore, this child should be assessed first.
1
,5. The nurse has received the a.m. shift report for clients on a pediatric unit. Which medicationshould the
nurse administer first?
A. The third dose of the aminoglycoside antibiotic to the child diagnosed with
methicillin-resistant Staphylococcus aureus (MRSA).
B. The IVP steroid methylprednisolone (Solu-Medrol) to the child diagnosed with
asthma.
2
, C. The sliding scale insulin to the child diagnosed with type 1 diabetes mellitus.
D. The stimulant methylphenidate (Ritalin) to a child diagnosed with attention
deficit-hyperactivity disorder (ADHD).
Rationale
ANS : C -Sliding scale insulin is ordered ac, which is before meals; therefore, this medication must beadministered
first after receiving the a.m. shift report.
4-Routine medications have a 1-hour leeway before and after the scheduled time; therefore, thismedication does not
have to be administered 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).
A. Perform cardiac compression 30:2.
B. Check the infant's brachial pulse.
C. Administer two puffs to the infant.
D. Determineunresponsiveness.
E. Open the infant's airway.
Rationale
ANS Answer: D, E, C, B, A
D.The nurse must first determine the infant's responsiveness by thumping the baby's feet.
E. The nurse should then open the child's airway using the head-tilt chin-lift tech- nique, with care takennot to
hyperextend the neck. Then the nurse should look, listen, and feel for respirations.
C. The nurse then administers quick puffs of air while covering the child's mouth and nose, preferablywith a
rescue mask.
B. The nurse should determine whether the infant has a pulse by checking the brachial artery.
A. If the infant has no pulse, the nurse should begin chest compressions using two fingers at a rate of30:2.
7. The 3-year-old client has been admitted to the pediatric unit. Which task should the nurseinstruct the
unlicensed assistive personnel (UAP) to perform first?
A. Orient the parents and child to the room.
B. Obtain an admission kit for the child.
C. Post the child's height and weight at the HOB.
D. Provide the child with a meal tray.
Rationale
ANS – A .The first intervention after the child is admitted to the unit is to orient the parents and child to the room,
the call system, and the hospital rules, such as not leaving the child alone in the room.
8. The clinic nurse is preparing to administer an intramuscular (IM) injection to the 2-year-old toddler.Which
intervention should the nurse implement first?
A. Immobilize the child's leg.
B. Explain the procedure to the child.
C. Cleanse the area with an alcohol swab.
D. Administer the medication in the thigh.
Rationale
ANS - B-The nurse must explain any procedure in words the child can understand. It does not matterhow old the
child is.
9. The nurse is writing a care plan for the 5-year-old child diagnosed with gastroenteritis. Which client problem is
priority?
3
, A. Imbalanced nutrition.
B. Fluid volume deficit.
C. Knowledge deficit.
D. Risk for infection.
Rationale
ANS - B-The child diagnosed with gastroenteritis is at high risk for hypovolemic shock resulting fromvomiting and
diarrhea; therefore, maintaining fluid and electrolyte homeostasis is priority.
10. Which data would warrant immediate intervention from the pediatric nurse?
A . Proteinuria for thechild diagnosed with nephrotic syndrome.
B.Petechiae for the child diagnosed with leukemia.
C. Drooling for a child diagnosed with acute epiglottitis.
D. Elevated temperature in a child diagnosed with otitis media.
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