Hesi Nursing Critical Thinking

1. The Patient: A 65-year- old male. The Situation: The family brings the patient to the emergency room because he just took an entire bottle of pills. The Question: What action should the nurse take first? A. Prescribe medicine to induce vomiting. B. Determine the patient's level of consciousness. C. Ask the family why he may have taken an entire bottle of pills. -(answer) B. Determine the patient's level of consciousness. 2. The Patient: An 80-year-old male who has used continuous oxygen for the past three years. The Situation: While making a home visit, the wife tells the nurse that her husband was doing well on 2 liters of oxygen per minute until late last night when he developed severe shortness of breath on the way to the bathroom. The Question: What action should the nurse take first? A. Assess the patient's oxygen saturation by a pulse oximeter. B. Ask the patient to lie down and wait to see if it happens again. C. Begin administering 2.5 liters of oxygen per minute. -(answer) A. Assess the patient's oxygen saturation by a pulse oximeter. 3. The Patient: A 41-year-old male. The Situation: The patient is complaining of severe stomach pain and states that he has been "vomiting all the time." The Question: What should the nurse do first? A. Prescribe an anti-vomiting medication B. Administer a prescribed pain medication C. Check for dehydration from vomiting. -(answer) B. Administer a prescribed pain medication 4. The Patient: The wife of a wealthy owner of the town's bank. The Situation: The patient and her husband arrive on the unit. While orienting the patient to the hospital room, the nurse notices that the patient has placed a large amount of cash and some expensive earrings in the drawer of the bedside table. The Question: What is the best action for the nurse to take? A. Advise the patient to have her husband take the items home when he leaves. B. Offer to put the items in a safe downstairs. C. Offer to put the items in the nurses' station. -(answer) A. Advise the patient to have her husband take the items home when he leaves. 5. The Patient: A 45-year-old female who is 5' 2" tall, weighs 200 pounds, and has smoked since age 21. The Situation: The patient comes to the clinic with a complaint of "leg pain." The Question: It is most important for the nurse to obtain information about which previous occurrence? A. Ask when the patient smoked her last cigarette. B. When did her leg hurt last, C. A previous blood clot in the leg -(answer) C. A previous blood clot in the leg 6. The Patient: A 61-year-old female. The Situation: The patient has a fever of unknown origin. The nurse administered a fever-reducing medication 30 minutes ago. At this time there has been no decrease in the patient's fever. The Question: What action would be best for the nurse to take? A. Give the patient more fever-reducing medication. B. Sponge the patient with cool water. C. Wait thirty more minutes for the medicine to kick in. -(answer) B. Sponge the patient with cool water. 7. The Patient: A 70-year-old male who is relatively healthy. The Situation: A liquid mediation is prescribed for this patient. The Question: Prior to administering the prescribed medication, what intervention has the highest priority? A. Determine if the patient is allergic to the medication B. Ask if the patient has taken any similar medications to that one. C. Determine the exact dosage needed. -(answer) A. Determine if the patient is allergic to the medication. 8. The Patient: A fifty-eight-year-old female. The Situation: While the nurse is offering the patient her morning medications, she tells the nurse that she does not recall ever taking a pill that was pink-colored. The Question: What should the nurse do in response to this patient's comment? A. Assume she is confused and continue to offer the medication. B. Withhold the medication until the patient's prescription is verified. C. Discard the medication. -(answer) B. Withhold the medication until the patient's prescription is verified. 9. The Patients: 1. A 63-year-old with a burn on the left lower leg is complaining of pain. 2. A 45-year-old with pneumonia, complaining of shortness of breath. 3. A 31-year-old with abdominal pain who has just vomited blood. 4. An 88-year-old who has right-sided paralysis and wants to be helped to the bathroom immediately. The Situation: The nurse is caring for these patients. The Question: Whom should the nurse see first? A. The 45-years old with pneumonia and shortness of breath. B. A 63-year-old with a burn on the left lower leg who is complaining of pain. C. A 31-year-old with abdominal pain who has just vomited blood. D. . An 88-year-old who has right-sided paralysis and wants to be helped to the bathroom immediately. -(answer) A. The 45-years old with pneumonia and shortness of breath. 10. The Patients: 1. A 13-year-old female with a kidney infection reports that there is "lots of blood" in her urine. 2. An 18-year-old male with acute alcohol poisoning who is seeing "bugs on the walls." 3. A 21-year-old female with inflammatory bowel disease who has soaked a dressing three hours after surgery. 4. A 25-year old male is sobbing in his room after being told that he has testicular cancer. The Situation: The nurse is caring for these four patients. The Question: Whom should the nurse see first? A. A 13-year-old female with a kidney infection reports that there is "lots of blood" in her urine. B. An 18-year-old male with acute alcohol poisoning who is seeing "bugs on the walls." C. A 21-year-old female with inflammatory bowel disease who has soaked a dressing three hours after surgery. D. A 25-year old male is sobbing in his room after being told that he has testicular cancer. -(answer) C. The 21-years old who is three hours postoperative and has a soaked dressing. 11. The Patients: 1. A 42-year-old with diabetes who is blind and is asking to get up and moved to a chair. 2. An 88-year-old with lower-body paralysis who wants to be turned in bed. 3. A 17-year-old with asthma who smokes and has been in the bathroom for 30 minutes. 4. A 55-year-old with cardiac disease tells the nurse, "Get the TV fixed or I am leaving this place." The Situation: The nurse is caring for these four patients. The Question: Which patient should the nurse see first? A. The 17-year old with asthma who may be smoking in the bathroom. B. A 42-year-old with diabetes who is blind and is asking to get up and moved to a chair. C. An 88-year-old with lower-body paralysis who wants to be turned in bed. D. A 55-year-old with cardiac disease tells the nurse, "Get the TV fixed or I am leaving this place." -(answer) A. The 17-year old with asthma who may be smoking in the bathroom. 12. The Patient: An elderly female accompanied by her middle-aged son. The Situation: The patient is being discharged after a 15-day stay in the medical unit, and the son offers the nurse a box of candy as a gesture of thanks for caring for his mother. The Question: What should the nurse do in response to the offer of this gift? A. Sincerely thank the son and take the candy home B. Sincerely thank the son, but tell her you do not eat candy. C. Sincerely thank the son and share the candy with all staff members on the units. - (answer) C Sincerely thank the son, and share the candy with all staff members on the unit. 13. The Patient: A 25-year-old female who has smoked since age 12. The Situation: The patient is complaining of "skipped heartbeats." The Question: Which instruction is most important for the nurse to provide this patient. A. Call for assistance if she feels week or dizzy when getting out of bed. B. Try to relax. C. Don't worry about it. -(answer) A. Call for assistance if she feels weak or dizzy when getting out of bed. 14. The Patient: A frail 88-year-old male who has recently become slightly confused. The Situation: The nurse is making a home visit and assesses the safety features of the