HESI A2 CRITICAL THINKING 2025
Course
HESI A2 CRITICAL THINKING
1.
Question: A nurse enters a room and finds a patient short of breath, with an O₂ saturation of
82%. What should the nurse do first?
A. Call the rapid response team
B. Administer oxygen
C. Notify the healthcare provider
D. Elevate the head of the bed
Answer: D. Elevate the head of the bed
Rationale: Prioritization follows the ABCs (airway, breathing, circulation). Elevating the head
of bed immediately improves lung expansion. Administering O₂ follows right after, but
positioning comes first because it is the quickest intervention.
2.
Question: A patient with diabetes is confused and sweaty. What action should the nurse take
first?
A. Check blood glucose
B. Give orange juice
C. Call the physician
D. Place patient on seizure precautions
Answer: A. Check blood glucose
Rationale: Symptoms suggest hypoglycemia, but the nurse must confirm with a glucose test
before treatment. This follows the principle: assess before intervene unless the situation is
immediately life-threatening.
3.
Question: The nurse is assigned four patients. Which patient should be assessed first?
A. Post-op hip replacement patient with mild pain
B. COPD patient with O₂ sat of 89%
C. Child with fever of 101.2°F
D. Patient receiving a blood transfusion, complaining of chills
,Answer: D. Patient receiving a blood transfusion, complaining of chills
Rationale: This may indicate a transfusion reaction, which is life-threatening. This patient takes
priority over stable COPD O₂ saturation and mild fever.
4.
Question: Which task is appropriate to delegate to a nursing assistant (UAP)?
A. Teaching patient insulin injection
B. Monitoring chest tube output
C. Obtaining routine vital signs
D. Assessing wound healing
Answer: C. Obtaining routine vital signs
Rationale: UAPs may perform noninvasive, routine tasks. Teaching, monitoring, and assessment
require RN judgment and cannot be delegated.
5.
Question: The nurse receives new lab values. Which finding is most concerning?
A. Potassium 5.1 mEq/L
B. Hemoglobin 11 g/dL
C. Sodium 129 mEq/L
D. WBC 11,200/mm³
Answer: C. Sodium 129 mEq/L
Rationale: Hyponatremia (<135) can lead to seizures and neurological issues. The other values
are only mildly abnormal.
6.
Question: A patient tells the nurse, “I feel like I’m going to die.” What should the nurse do first?
A. Ask about chest pain
B. Notify the provider
C. Document the statement
D. Administer prescribed anti-anxiety medication
Answer: A. Ask about chest pain
Rationale: Sudden sense of doom may indicate myocardial infarction or PE. The nurse must
assess for acute, life-threatening causes before attributing to anxiety.
, 7.
Question: The nurse is caring for a post-op patient who reports pain at 8/10 but is smiling and
talking with visitors. What is the best action?
A. Delay pain meds since patient doesn’t appear distressed
B. Reassess after visitors leave
C. Administer pain medication as prescribed
D. Document that the patient is not in pain
Answer: C. Administer pain medication as prescribed
Rationale: Pain is subjective. The nurse must treat reported pain, regardless of outward
appearance.
8.
Question: Which action is most appropriate for preventing medication errors?
A. Preparing meds for two patients at the same time
B. Asking another nurse to verify unclear handwriting
C. Using the 5 rights of medication administration
D. Relying on memory for routine orders
Answer: C. Using the 5 rights of medication administration
Rationale: Verifying right patient, drug, dose, route, and time is the foundation of safe practice.
Preparing for multiple patients at once increases error risk.
9.
Question: A nurse notices that a new graduate is about to administer insulin without checking
the patient’s blood sugar. What should the nurse do?
A. Allow them to proceed for learning purposes
B. Step in and stop the administration
C. Report to the charge nurse after the fact
D. Assume the graduate already checked
Answer: B. Step in and stop the administration
Rationale: Patient safety is priority. Immediate intervention prevents harm. Later, the nurse can
provide teaching and report if necessary.
Course
HESI A2 CRITICAL THINKING
1.
Question: A nurse enters a room and finds a patient short of breath, with an O₂ saturation of
82%. What should the nurse do first?
A. Call the rapid response team
B. Administer oxygen
C. Notify the healthcare provider
D. Elevate the head of the bed
Answer: D. Elevate the head of the bed
Rationale: Prioritization follows the ABCs (airway, breathing, circulation). Elevating the head
of bed immediately improves lung expansion. Administering O₂ follows right after, but
positioning comes first because it is the quickest intervention.
2.
Question: A patient with diabetes is confused and sweaty. What action should the nurse take
first?
A. Check blood glucose
B. Give orange juice
C. Call the physician
D. Place patient on seizure precautions
Answer: A. Check blood glucose
Rationale: Symptoms suggest hypoglycemia, but the nurse must confirm with a glucose test
before treatment. This follows the principle: assess before intervene unless the situation is
immediately life-threatening.
3.
Question: The nurse is assigned four patients. Which patient should be assessed first?
A. Post-op hip replacement patient with mild pain
B. COPD patient with O₂ sat of 89%
C. Child with fever of 101.2°F
D. Patient receiving a blood transfusion, complaining of chills
,Answer: D. Patient receiving a blood transfusion, complaining of chills
Rationale: This may indicate a transfusion reaction, which is life-threatening. This patient takes
priority over stable COPD O₂ saturation and mild fever.
4.
Question: Which task is appropriate to delegate to a nursing assistant (UAP)?
A. Teaching patient insulin injection
B. Monitoring chest tube output
C. Obtaining routine vital signs
D. Assessing wound healing
Answer: C. Obtaining routine vital signs
Rationale: UAPs may perform noninvasive, routine tasks. Teaching, monitoring, and assessment
require RN judgment and cannot be delegated.
5.
Question: The nurse receives new lab values. Which finding is most concerning?
A. Potassium 5.1 mEq/L
B. Hemoglobin 11 g/dL
C. Sodium 129 mEq/L
D. WBC 11,200/mm³
Answer: C. Sodium 129 mEq/L
Rationale: Hyponatremia (<135) can lead to seizures and neurological issues. The other values
are only mildly abnormal.
6.
Question: A patient tells the nurse, “I feel like I’m going to die.” What should the nurse do first?
A. Ask about chest pain
B. Notify the provider
C. Document the statement
D. Administer prescribed anti-anxiety medication
Answer: A. Ask about chest pain
Rationale: Sudden sense of doom may indicate myocardial infarction or PE. The nurse must
assess for acute, life-threatening causes before attributing to anxiety.
, 7.
Question: The nurse is caring for a post-op patient who reports pain at 8/10 but is smiling and
talking with visitors. What is the best action?
A. Delay pain meds since patient doesn’t appear distressed
B. Reassess after visitors leave
C. Administer pain medication as prescribed
D. Document that the patient is not in pain
Answer: C. Administer pain medication as prescribed
Rationale: Pain is subjective. The nurse must treat reported pain, regardless of outward
appearance.
8.
Question: Which action is most appropriate for preventing medication errors?
A. Preparing meds for two patients at the same time
B. Asking another nurse to verify unclear handwriting
C. Using the 5 rights of medication administration
D. Relying on memory for routine orders
Answer: C. Using the 5 rights of medication administration
Rationale: Verifying right patient, drug, dose, route, and time is the foundation of safe practice.
Preparing for multiple patients at once increases error risk.
9.
Question: A nurse notices that a new graduate is about to administer insulin without checking
the patient’s blood sugar. What should the nurse do?
A. Allow them to proceed for learning purposes
B. Step in and stop the administration
C. Report to the charge nurse after the fact
D. Assume the graduate already checked
Answer: B. Step in and stop the administration
Rationale: Patient safety is priority. Immediate intervention prevents harm. Later, the nurse can
provide teaching and report if necessary.
