A PACKAGE DEAL FOR HESI A2 CRITICAL THINKING V1,
V2 AND V3 2023 UPDATE
1. The nurse is working in the emergency department (ED) of a children's medical
center. Which client should the nurse assess first?
1. The 1-month-old infant who has developed colic and is crying.
2. The 2-year-old toddler who was bitten by another child at the day-care center. 3.
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. -
ANSWER: 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.
1. In an interview, the nurse may find it necessary to take notes to aid his or her
memory later. Which statement is true regarding note-taking?
A) Note-taking may impede the nurse's observation of the patient's nonverbal
behaviors.
B) Note-taking allows the patient to continue at his or her own pace as the nurse
records what is said.
C) Note-taking allows the nurse to shift attention away from the patient, resulting in
an increased comfort level.
D) Note-taking allows the nurse to break eye contact with the patient, which may
increase his or her level of comfort. - ANSWER: A) Note-taking may impede the
nurse's observation of the patient's nonverbal behaviors.
Page: 31 Some use of history forms and note-taking may be unavoidable. But be
aware that note-taking during the interview has disadvantages. It breaks eye contact
too often, and it shifts attention away from the patient, which diminishes his or her
sense of importance. It also may interrupt the patient's narrative flow, and it
impedes the observation of the patient's nonverbal behavior.
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.
2. During an interview, the nurse states, "You mentioned shortness of breath. Tell
me more about that." Which verbal skill is used with this statement?
,A) Reflection
B) Facilitation
C) Direct question
D) Open-ended question - ANSWER: D) Open-ended question
Page: 32 The open-ended question asks for narrative information. It states the topic
to be discussed but only in general terms. The nurse should use it to begin the
interview, to introduce a new section of questions, and whenever the person
introduces a new topic.
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.
3. A nurse is taking complete health histories on all of the patients attending a
wellness workshop. On the history form, one of the written questions asks, "You
don't smoke, drink, or take drugs, do you?" This question is an example of:
A) talking too much.
B) using confrontation.
C) using biased or leading questions.
D) using blunt language to deal with distasteful topics. - ANSWER: C) using biased or
leading questions.
Page: 36 This is an example of using leading or biased questions. Asking, "You don't
smoke, do you?" implies that one answer is "better" than another. If the person
wants to please someone, he or she is either forced to answer in a way
corresponding to their implied values or is made to feel guilty when admitting the
other answer.
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.
4. During an interview, a parent of a hospitalized child is sitting in an open position.
As the interviewer begins to discuss his son's treatment, however, he suddenly
crosses his arms against his chest and crosses his legs. This would suggest that the
parent is:
A) just changing positions.
B) more comfortable in this position.
C) tired and needs a break from the interview.
D) uncomfortable talking about his son's treatment. - ANSWER: D) uncomfortable
talking about his son's treatment.
Page: 37 Note the person's position. An open position with the extension of large
muscle groups shows relaxation, physical comfort, and a willingness to share
information. A closed position with the arms and legs crossed tends to look
defensive and anxious. Note any change in posture. If a person in a relaxed position
suddenly tenses, it suggests possible discomfort with the new topic.
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.
5. The nurse is interviewing a patient who has a hearing impairment. What
techniques would be most beneficial in communicating with this patient?
A) Determine the communication method he prefers.
B) Avoid using facial and hand gestures because most hearing-impaired people find
this degrading.
C) Request a sign language interpreter before meeting with him to help facilitate the
communication.
, D) Speak loudly and with exaggerated facial movement when talking with him
because this helps with lip reading. - ANSWER: A) Determine the communication
method he prefers.
Pages: 40-41 The nurse should ask the deaf person the preferred way to
communicate—by signing, lip reading, or writing. If the person prefers lip reading,
then the nurse should be sure to face him or her squarely and have good lighting on
the nurse's face. The nurse should not exaggerate lip movements because this
distorts words. Similarly, shouting distorts the reception of a hearing aid the person
may wear. The nurse should speak slowly and should supplement his or her voice
with appropriate hand gestures or pantomime.
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.
6. The nurse is performing a health interview on a patient who has a language
barrier, and no interpreter is available. Which is the best example of an appropriate
question for the nurse to ask in this situation?
A) "Do you take medicine?"
B) "Do you sterilize the bottles?"
C) "Do you have nausea and vomiting?"
D) "You have been taking your medicine, haven't you?" - ANSWER: A) "Do you take
medicine?"
Page: 46 In a situation where there is a language barrier and no interpreter available,
use simple words avoiding medical jargon. Avoid using contractions and pronouns.
Use nouns repeatedly and discuss one topic at a time.
V2 AND V3 2023 UPDATE
1. The nurse is working in the emergency department (ED) of a children's medical
center. Which client should the nurse assess first?
1. The 1-month-old infant who has developed colic and is crying.
2. The 2-year-old toddler who was bitten by another child at the day-care center. 3.
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. -
ANSWER: 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.
1. In an interview, the nurse may find it necessary to take notes to aid his or her
memory later. Which statement is true regarding note-taking?
A) Note-taking may impede the nurse's observation of the patient's nonverbal
behaviors.
B) Note-taking allows the patient to continue at his or her own pace as the nurse
records what is said.
C) Note-taking allows the nurse to shift attention away from the patient, resulting in
an increased comfort level.
D) Note-taking allows the nurse to break eye contact with the patient, which may
increase his or her level of comfort. - ANSWER: A) Note-taking may impede the
nurse's observation of the patient's nonverbal behaviors.
Page: 31 Some use of history forms and note-taking may be unavoidable. But be
aware that note-taking during the interview has disadvantages. It breaks eye contact
too often, and it shifts attention away from the patient, which diminishes his or her
sense of importance. It also may interrupt the patient's narrative flow, and it
impedes the observation of the patient's nonverbal behavior.
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.
2. During an interview, the nurse states, "You mentioned shortness of breath. Tell
me more about that." Which verbal skill is used with this statement?
,A) Reflection
B) Facilitation
C) Direct question
D) Open-ended question - ANSWER: D) Open-ended question
Page: 32 The open-ended question asks for narrative information. It states the topic
to be discussed but only in general terms. The nurse should use it to begin the
interview, to introduce a new section of questions, and whenever the person
introduces a new topic.
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.
3. A nurse is taking complete health histories on all of the patients attending a
wellness workshop. On the history form, one of the written questions asks, "You
don't smoke, drink, or take drugs, do you?" This question is an example of:
A) talking too much.
B) using confrontation.
C) using biased or leading questions.
D) using blunt language to deal with distasteful topics. - ANSWER: C) using biased or
leading questions.
Page: 36 This is an example of using leading or biased questions. Asking, "You don't
smoke, do you?" implies that one answer is "better" than another. If the person
wants to please someone, he or she is either forced to answer in a way
corresponding to their implied values or is made to feel guilty when admitting the
other answer.
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.
4. During an interview, a parent of a hospitalized child is sitting in an open position.
As the interviewer begins to discuss his son's treatment, however, he suddenly
crosses his arms against his chest and crosses his legs. This would suggest that the
parent is:
A) just changing positions.
B) more comfortable in this position.
C) tired and needs a break from the interview.
D) uncomfortable talking about his son's treatment. - ANSWER: D) uncomfortable
talking about his son's treatment.
Page: 37 Note the person's position. An open position with the extension of large
muscle groups shows relaxation, physical comfort, and a willingness to share
information. A closed position with the arms and legs crossed tends to look
defensive and anxious. Note any change in posture. If a person in a relaxed position
suddenly tenses, it suggests possible discomfort with the new topic.
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.
5. The nurse is interviewing a patient who has a hearing impairment. What
techniques would be most beneficial in communicating with this patient?
A) Determine the communication method he prefers.
B) Avoid using facial and hand gestures because most hearing-impaired people find
this degrading.
C) Request a sign language interpreter before meeting with him to help facilitate the
communication.
, D) Speak loudly and with exaggerated facial movement when talking with him
because this helps with lip reading. - ANSWER: A) Determine the communication
method he prefers.
Pages: 40-41 The nurse should ask the deaf person the preferred way to
communicate—by signing, lip reading, or writing. If the person prefers lip reading,
then the nurse should be sure to face him or her squarely and have good lighting on
the nurse's face. The nurse should not exaggerate lip movements because this
distorts words. Similarly, shouting distorts the reception of a hearing aid the person
may wear. The nurse should speak slowly and should supplement his or her voice
with appropriate hand gestures or pantomime.
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.
6. The nurse is performing a health interview on a patient who has a language
barrier, and no interpreter is available. Which is the best example of an appropriate
question for the nurse to ask in this situation?
A) "Do you take medicine?"
B) "Do you sterilize the bottles?"
C) "Do you have nausea and vomiting?"
D) "You have been taking your medicine, haven't you?" - ANSWER: A) "Do you take
medicine?"
Page: 46 In a situation where there is a language barrier and no interpreter available,
use simple words avoiding medical jargon. Avoid using contractions and pronouns.
Use nouns repeatedly and discuss one topic at a time.
