HESI A2 CRITICAL THINKING 2024 QUESTIONS AND
UPDATED 100% CORRECT ANSWERS WITH RATIONALES/
A+ GRADE
• The nurse is working in the emergency department (ED) of a children's
medical center. Which client should the nurse assess first?
• The 1-month-old infant who has developed colic and is crying.
• The 2-year-old toddler who was bitten by another child at the day-care center.
• The 6- year-old school-age child who was hit by a car while riding a bicycle.
4. The 14-year-old adolescent whose mother suspects her child is sexually active. -
correct answers.Rationale
Correct - 3-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 a severe headache. Which intervention should the nurse implement
first?
• Administer 6 L of oxygen via nasal cannula.
• Assess the client's neurological status.
• Administer a narcotic analgesic by intravenous push (IVP).
• Increase the client's intravenous (IV) rate. - correct answers.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.
• 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?
• Praise the child for the attempt to make the pinwheel spin.
• Notify the respiratory therapist to implement incentive spirometry.
• Encourage the child to turn from side to side and cough.
• Demonstrate how to make the pinwheel spin by blowing on it. - correct
answers.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?
,• The child diagnosed with type 1 diabetes who has a blood
glucose level of 180 mg/dL.
• The child diagnosed with pneumonia who is coughing and has a
temperature of 100°F.
• The child diagnosed with gastroenteritis who has a potassium
(K+) level of 3.9 mEq/L.
• The child diagnosed with cystic fibrosis who has a pulse oximeter reading of 90%.
- correct answers.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.
• The nurse has received the a.m. shift report for clients on a pediatric unit. Which
medication should the nurse administer first?
• The third dose of the aminoglycoside antibiotic to the child
diagnosed with methicillin-resistant Staphylococcus aureus
(MRSA).
• The IVP steroid methylprednisolone (Solu-Medrol) to the child
diagnosed with asthma.
• The sliding scale insulin to the child diagnosed with type 1 diabetes mellitus.
• The stimulant methylphenidate (Ritalin) to a child diagnosed with
attention deficit-hyperactivity disorder (ADHD). - correct
answers.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.
• 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).
• Perform cardiac compression 30:2.
• Check the infant's brachial pulse.
• Administer two puffs to the infant.
• Determine unresponsiveness.
• Open the infant's airway. - correct
answers.Rationale Correct Answer: 4, 5, 3, 2,
1
• The nurse must first determine the infant's responsiveness by thumping the baby's feet.
• 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.
• 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.
• The 3-year-old client has been admitted to the pediatric unit. Which task should
the nurse instruct the unlicensed assistive personnel (UAP) to perform first?
• Orient the parents and child to the room.
• Obtain an admission kit for the child.
• Post the child's height and weight at the HOB. 4. Provide the child with a meal tray.
- correct answers.Rationale
Correct - 1.The first intervention after the child is ad- mitted 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.
• The clinic nurse is preparing to administer an intramuscular (IM) injection to the
2-year-old toddler. Which intervention should the nurse implement first?
• Immobilize the child's leg.
• Explain the procedure to the child.
• Cleanse the area with an alcohol swab. 4. Administer the medication in the thigh.
- correct answers.Rationale
Correct - 2-The nurse must explain any procedure in words the child can understand.
It does not matter how old the child is.
• The nurse is writing a care plan for the 5-year-old child diagnosed with
gastroenteritis. Which client problem is priority?
• Imbalanced nutrition.
• Fluid volume deficit.
• Knowledge deficit.
• Risk for infection. - correct answers.Rationale
Correct - 2-The child diagnosed with gastroenteritis is at high risk for hypovolemic
shock resulting from vomiting and diarrhea; therefore, maintaining fluid and elec-
trolyte homeostasis is priority.
• Which data would warrant immediate intervention from the pediatric nurse? 1.
Proteinuria for the child diagnosed with nephrotic syndrome.
• Petechiae for the child diagnosed with leukemia.
• Drooling for a child diagnosed with acute epiglottitis.
• Elevated temperature in a child diagnosed with otitis media. - correct
answers.Rationale Correct - 3-Drooling indicates the child is having trouble
swallowing, and the epiglottis is at risk of completely occluding the air- way. This
warrants immediate interven- tion. The nurse should notify the HCP and obtain an
emergency tracheostomy tray for the bedside.
, • Which client should the pediatric nurse assess first after receiving the a.m. shift
report? 1.
The 6-month old child diagnosed with bacterial meningitis who is irritable
and crying.
• The 9-month old child diagnosed with tetralogy of Fallot (TOF) who has
edema of the face.
• The 11-month old child diagnosed with Reye syndrome who is
lethargic and vomiting.
• The 13-month-old child diagnosed with diarrhea who has sunken
eyeballs and decreased urine output. - correct answers.Rationale
Correct - 4. Sunken eyeballs and decreased urine out- put are signs of dehydration,
which is a life-threatening complication of diarrhea; therefore, this child should be
assessed first.
• The pediatric clinic nurse is triaging telephone calls. Which client's parent should
the nurse call first?
• The 4-month-old child who had immunizations yesterday and the parent is
report- ing a high-pitched cry and a 103°F fever.
• The 8-month-old whose parent is reporting the child is pulling on the right ear
and has a fever.
• The 2-year-old child who has patent ductus arteriosis whose parent reports
running out of digoxin.
• The 3-year-old child whose mother called and reported her daughter may have
chickenpox.
- correct answers.Rationale
Correct 1-A high fever and high-pitched crying may indicate a reaction to the
immunizations; therefore, this parent needs to be called first to bring the child to the
clinic.
• The parent of a 12-year-old male child with a left below-the-knee cast calls the
pedi- atric clinic nurse and tells the nurse, "My son's foot is cold and he told me it
feels like his foot is asleep." Which action should the nurse implement first?
• Prepare to bifurcate the left below-the-knee cast.
• Tell the parent to bring the child to the office.
• Instruct the parent to elevate the left leg on two pillows.
• Notify the child's orthopedist of the situation. - correct answers.Rationale
Correct - 3. The nurse should first take care of the client's body by having the parent
elevate the left leg.
• Which child requires the nurse to notify the healthcare provider?
• The 1-year-old child with iron deficiency anemia who has dark-colored stool.
• The 3-year-old child with phenylketonuria (PKU) whose parent does not
feed the child any meat or milk products.
• The 5-year-old child with rheumatic heart fever who is having difficulty breathing.
• The 7-year-old child diagnosed with acute glomerulonephritis who
has dark "tea"-colored urine. - correct answers.Rationale
UPDATED 100% CORRECT ANSWERS WITH RATIONALES/
A+ GRADE
• The nurse is working in the emergency department (ED) of a children's
medical center. Which client should the nurse assess first?
• The 1-month-old infant who has developed colic and is crying.
• The 2-year-old toddler who was bitten by another child at the day-care center.
• The 6- year-old school-age child who was hit by a car while riding a bicycle.
4. The 14-year-old adolescent whose mother suspects her child is sexually active. -
correct answers.Rationale
Correct - 3-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 a severe headache. Which intervention should the nurse implement
first?
• Administer 6 L of oxygen via nasal cannula.
• Assess the client's neurological status.
• Administer a narcotic analgesic by intravenous push (IVP).
• Increase the client's intravenous (IV) rate. - correct answers.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.
• 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?
• Praise the child for the attempt to make the pinwheel spin.
• Notify the respiratory therapist to implement incentive spirometry.
• Encourage the child to turn from side to side and cough.
• Demonstrate how to make the pinwheel spin by blowing on it. - correct
answers.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?
,• The child diagnosed with type 1 diabetes who has a blood
glucose level of 180 mg/dL.
• The child diagnosed with pneumonia who is coughing and has a
temperature of 100°F.
• The child diagnosed with gastroenteritis who has a potassium
(K+) level of 3.9 mEq/L.
• The child diagnosed with cystic fibrosis who has a pulse oximeter reading of 90%.
- correct answers.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.
• The nurse has received the a.m. shift report for clients on a pediatric unit. Which
medication should the nurse administer first?
• The third dose of the aminoglycoside antibiotic to the child
diagnosed with methicillin-resistant Staphylococcus aureus
(MRSA).
• The IVP steroid methylprednisolone (Solu-Medrol) to the child
diagnosed with asthma.
• The sliding scale insulin to the child diagnosed with type 1 diabetes mellitus.
• The stimulant methylphenidate (Ritalin) to a child diagnosed with
attention deficit-hyperactivity disorder (ADHD). - correct
answers.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.
• 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).
• Perform cardiac compression 30:2.
• Check the infant's brachial pulse.
• Administer two puffs to the infant.
• Determine unresponsiveness.
• Open the infant's airway. - correct
answers.Rationale Correct Answer: 4, 5, 3, 2,
1
• The nurse must first determine the infant's responsiveness by thumping the baby's feet.
• 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.
• 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.
• The 3-year-old client has been admitted to the pediatric unit. Which task should
the nurse instruct the unlicensed assistive personnel (UAP) to perform first?
• Orient the parents and child to the room.
• Obtain an admission kit for the child.
• Post the child's height and weight at the HOB. 4. Provide the child with a meal tray.
- correct answers.Rationale
Correct - 1.The first intervention after the child is ad- mitted 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.
• The clinic nurse is preparing to administer an intramuscular (IM) injection to the
2-year-old toddler. Which intervention should the nurse implement first?
• Immobilize the child's leg.
• Explain the procedure to the child.
• Cleanse the area with an alcohol swab. 4. Administer the medication in the thigh.
- correct answers.Rationale
Correct - 2-The nurse must explain any procedure in words the child can understand.
It does not matter how old the child is.
• The nurse is writing a care plan for the 5-year-old child diagnosed with
gastroenteritis. Which client problem is priority?
• Imbalanced nutrition.
• Fluid volume deficit.
• Knowledge deficit.
• Risk for infection. - correct answers.Rationale
Correct - 2-The child diagnosed with gastroenteritis is at high risk for hypovolemic
shock resulting from vomiting and diarrhea; therefore, maintaining fluid and elec-
trolyte homeostasis is priority.
• Which data would warrant immediate intervention from the pediatric nurse? 1.
Proteinuria for the child diagnosed with nephrotic syndrome.
• Petechiae for the child diagnosed with leukemia.
• Drooling for a child diagnosed with acute epiglottitis.
• Elevated temperature in a child diagnosed with otitis media. - correct
answers.Rationale Correct - 3-Drooling indicates the child is having trouble
swallowing, and the epiglottis is at risk of completely occluding the air- way. This
warrants immediate interven- tion. The nurse should notify the HCP and obtain an
emergency tracheostomy tray for the bedside.
, • Which client should the pediatric nurse assess first after receiving the a.m. shift
report? 1.
The 6-month old child diagnosed with bacterial meningitis who is irritable
and crying.
• The 9-month old child diagnosed with tetralogy of Fallot (TOF) who has
edema of the face.
• The 11-month old child diagnosed with Reye syndrome who is
lethargic and vomiting.
• The 13-month-old child diagnosed with diarrhea who has sunken
eyeballs and decreased urine output. - correct answers.Rationale
Correct - 4. Sunken eyeballs and decreased urine out- put are signs of dehydration,
which is a life-threatening complication of diarrhea; therefore, this child should be
assessed first.
• The pediatric clinic nurse is triaging telephone calls. Which client's parent should
the nurse call first?
• The 4-month-old child who had immunizations yesterday and the parent is
report- ing a high-pitched cry and a 103°F fever.
• The 8-month-old whose parent is reporting the child is pulling on the right ear
and has a fever.
• The 2-year-old child who has patent ductus arteriosis whose parent reports
running out of digoxin.
• The 3-year-old child whose mother called and reported her daughter may have
chickenpox.
- correct answers.Rationale
Correct 1-A high fever and high-pitched crying may indicate a reaction to the
immunizations; therefore, this parent needs to be called first to bring the child to the
clinic.
• The parent of a 12-year-old male child with a left below-the-knee cast calls the
pedi- atric clinic nurse and tells the nurse, "My son's foot is cold and he told me it
feels like his foot is asleep." Which action should the nurse implement first?
• Prepare to bifurcate the left below-the-knee cast.
• Tell the parent to bring the child to the office.
• Instruct the parent to elevate the left leg on two pillows.
• Notify the child's orthopedist of the situation. - correct answers.Rationale
Correct - 3. The nurse should first take care of the client's body by having the parent
elevate the left leg.
• Which child requires the nurse to notify the healthcare provider?
• The 1-year-old child with iron deficiency anemia who has dark-colored stool.
• The 3-year-old child with phenylketonuria (PKU) whose parent does not
feed the child any meat or milk products.
• The 5-year-old child with rheumatic heart fever who is having difficulty breathing.
• The 7-year-old child diagnosed with acute glomerulonephritis who
has dark "tea"-colored urine. - correct answers.Rationale
