HESI A2 - Critical Thinking Exam
Questions With New Update Solutions
And Rationales | Verified
/. 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.
/.7. A female patient does not speak English well, and the nurse needs to choose an
interpreter. Which of the following would be the most appropriate choice?
A) A trained interpreter
B) A male family member
C) A female family member
D) A volunteer college student from the foreign language studies department - Answer-
A) A trained interpreter
Page: 46 whenever possible, the nurse should use a trained interpreter, preferably one
who knows medical terminology. In general, an older, more mature interpreter is
preferred to a younger, less experienced one, and the same gender is preferred when
possible.
Questions With New Update Solutions
And Rationales | Verified
/. 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.
/.7. A female patient does not speak English well, and the nurse needs to choose an
interpreter. Which of the following would be the most appropriate choice?
A) A trained interpreter
B) A male family member
C) A female family member
D) A volunteer college student from the foreign language studies department - Answer-
A) A trained interpreter
Page: 46 whenever possible, the nurse should use a trained interpreter, preferably one
who knows medical terminology. In general, an older, more mature interpreter is
preferred to a younger, less experienced one, and the same gender is preferred when
possible.
