HESI A2 - CRITICAL THINKING EXAM
QUESTIONS AND ANSWERS
1. The nurse is working in the emergency department (ED) of a children's medical ce
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nter. Which client should the nurse assess first?
rv rv rv rv rv rv rv
1. The 1-month-old infant who has developed colic and is crying.
rv rv rv rv rv rv rv rv rv rv
2. The 2-year-old toddler who was bitten by another child at the day-
rv rv rv rv rv rv rv rv rv rv rv rv
care center. 3. The 6-year-old school-
rv rv rv rv rv
age child who was hit by a car while riding a bicycle.
rv rv rv rv rv rv rv rv rv rv rv
4. The 14-year-old adolescent whose mother suspects her child is sexually active. -
rv rv rv rv rv rv rv rv rv rv rv rv
ANSWERS--Rationale
rv rv
Correct - 3- rv rv
The child hit by a car should be assessed first because he or she may have life-
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
threatening injuries that must be assessed and treated promptly.
rv rv rv rv rv rv rv rv rv
1. In an interview, the nurse may find it necessary to take notes to aid his or her me
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
mory later. Which statement is true regarding note-taking?
rv rv rv rv rv rv rv rv
A) Note- rv
taking may impede the nurse's observation of the patient's nonverbal behaviors.
rv rv rv rv rv rv rv rv rv rv
B) Note- rv
taking allows the patient to continue at his or her own pace as the nurse records wha
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
t is said.
rv rv
C) Note- rv
taking allows the nurse to shift attention away from the patient, resulting in an increa
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
sed comfort level. rv rv
D) Note- rv
taking allows the nurse to break eye contact with the patient, which may increase his
rv rv rv rv rv rv rv rv rv rv rv rv rv rv r
vor her level of comfort. - ANSWERS--A) Note-
rv rv rv rv rv rv rv
taking may impede the nurse's observation of the patient's nonverbal behaviors.
rv rv rv rv rv rv rv rv rv rv
Page: 31 Some use of history forms and note-
rv rv rv rv rv rv rv rv
taking may be unavoidable. But be aware that note-
rv rv rv rv rv rv rv rv
taking during the interview has disadvantages. It breaks eye contact too often, and it
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
shifts attention away from the patient, which diminishes his or her sense of importanc
rv rv rv rv rv rv rv rv rv rv rv rv rv
e. It also may interrupt the patient's narrative flow, and it impedes the observation of
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
the patient's nonverbal behavior.
rv rv rv
2. The 8-year-old client diagnosed with a vaso-
rv rv rv rv rv rv rv
occlusive sickle cell crisis is complaining of a severe headache. Which intervention s
rv rv rv rv rv rv rv rv rv rv rv rv
hould the nurse implement first?
rv rv rv rv
1. Administer 6 L of oxygen via nasal cannula.
rv rv rv rv rv rv rv rv
2. Assess the client's neurological status.
rv rv rv rv rv
3. Administer a narcotic analgesic by intravenous push (IVP). 4. Increase the client's
rv rv rv rv rv rv rv rv rv rv rv rv rv
intravenous (IV) rate. - ANSWERS--Rationale rv rv rv rv rv
,Correct - 2- rv rv
Because the client is complaining of a headache, the nurse should first rule out cere
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
brovascular accident (CVA) by assess- rv rv rv rv
ing the client's neurological status and then determine whether it is a headache that
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
can be treated with medication.
rv rv rv rv
2. During an interview, the nurse states, "You mentioned shortness of breath. Tell m
rv rv rv rv rv rv rv rv rv rv rv rv rv
e more about that." Which verbal skill is used with this statement?
rv rv rv rv rv rv rv rv rv rv rv
A) Reflection
rv
B) Facilitation
rv
C) Direct question
rv rv
D) Open-ended question - ANSWERS--D) Open-ended question
rv rv rv rv rv rv
Page: 32 The open- rv rv rv
ended question asks for narrative information. It states the topic to be discussed but
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
only in general terms. The nurse should use it to begin the interview, to introduce a n
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
ew section of questions, and whenever the person introduces a new topic.
rv rv rv rv rv rv rv rv rv rv rv
3. The 6-year-
rv rv
old client who has undergone abdominal surgery is attempting to make a pinwheel s
rv rv rv rv rv rv rv rv rv rv rv rv rv
pin by blowing on it with the nurse's assistance. The child starts crying because the p
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
inwheel won't spin. Which action should the nurse implement first?
rv rv rv rv rv rv rv rv rv
1. Praise the child for the attempt to make the pinwheel spin.
rv rv rv rv rv rv rv rv rv rv rv
2. Notify the respiratory therapist to implement incentive spirometry. 3. Encourage th
rv rv rv rv rv rv rv rv rv rv rv
e child to turn from side to side and cough.
rv rv rv rv rv rv rv rv rv
4. Demonstrate how to make the pinwheel spin by blowing on it. - ANSWERS--
rv rv rv rv rv rv rv rv rv rv rv rv rv
Rationale rv
Correct - rv
1. The nurse should always praise the child for attempts at cooperation even if the c
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
hild did not accomplish what the nurse asked.
rv rv rv rv rv rv rv
3. A nurse is taking complete health histories on all of the patients attending a wellne
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
ss workshop. On the history form, one of the written questions asks, "You don't smok
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
e, drink, or take drugs, do you?" This question is an example of:
rv rv rv rv rv rv rv rv rv rv rv rv
A) talking too much.
rv rv rv
B) using confrontation.
rv rv
C) using biased or leading questions.
rv rv rv rv rv
D) using blunt language to deal with distasteful topics. - ANSWERS--
rv rv rv rv rv rv rv rv rv rv
C) using biased or leading questions.
rv rv rv rv rv
Page: 36 This is an example of using leading or biased questions. Asking, "You don't
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
smoke, do you?" implies that one answer is "better" than another. If the person want
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
s to please someone, he or she is either forced to answer in a way corresponding to
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
their implied values or is made to feel guilty when admitting the other answer.
rv rv rv rv rv rv rv rv rv rv rv rv rv
4. The nurse is caring for clients on the pediatric medical unit. Which client should th
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
e nurse assess first?
rv rv rv
,1. The child diagnosed with type 1 diabetes who has a blood glucose level
rv rv rv rv rv rv rv rv rv rv rv rv rv
of 180 mg/dL.
rv rv
2. The child diagnosed with pneumonia who is coughing and has a temperature of
rv rv rv rv rv rv rv rv rv rv rv rv rv
100°F.
3. The child diagnosed with gastroenteritis who has a potassium (K+) level
rv rv rv rv rv rv rv rv rv rv rv
of 3.9 mEq/L.
rv rv
4. The child diagnosed with cystic fibrosis who has a pulse oximeter reading of 90%.
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
- ANSWERS--Rationale
rv rv
Correct - rv
4. A pulse oximeter reading of less than 93% is significant and indicates hypoxia, wh
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
ich is life threatening; therefore, this child should be assessed first.
rv rv rv rv rv rv rv rv rv rv
4. During an interview, a parent of a hospitalized child is sitting in an open position. A
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
s the interviewer begins to discuss his son's treatment, however, he suddenly crosse
rv rv rv rv rv rv rv rv rv rv rv rv
s his arms against his chest and crosses his legs. This would suggest that the parent
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
is:
rv
A) just changing positions.
rv rv rv
B) more comfortable in this position.
rv rv rv rv rv
C) tired and needs a break from the interview.
rv rv rv rv rv rv rv rv
D) uncomfortable talking about his son's treatment. - ANSWERS--
rv rv rv rv rv rv rv rv
D) uncomfortable talking about his son's treatment.
rv rv rv rv rv rv
Page: 37 Note the person's position. An open position with the extension of large mu
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
scle groups shows relaxation, physical comfort, and a willingness to share informatio
rv rv rv rv rv rv rv rv rv rv rv
n. A closed position with the arms and legs crossed tends to look defensive and anxi
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
ous. Note any change in posture. If a person in a relaxed position suddenly tenses, it
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv r
suggests possible discomfort with the new topic.
v rv rv rv rv rv rv
5. The nurse has received the a.m. shift report for clients on a pediatric unit. Which
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
medication should the nurse administer first? rv rv rv rv rv
1. The third dose of the aminoglycoside antibiotic to the child diagnosed with
rv rv rv rv rv rv rv rv rv rv rv rv
methicillin-resistant Staphylococcus aureus (MRSA). rv rv rv
2. The IVP steroid methylprednisolone (Solu-Medrol) to the child diagnosed with
rv rv rv rv rv rv rv rv rv rv
asthma.
3. The sliding scale insulin to the child diagnosed with type 1 diabetes mellitus.
rv rv rv rv rv rv rv rv rv rv rv rv rv
4. The stimulant methylphenidate (Ritalin) to a child diagnosed with attention
rv rv rv rv rv rv rv rv rv rv
deficit-hyperactivity disorder (ADHD). - ANSWERS--Rationale rv rv rv rv rv
Correct - 3- rv rv
Sliding scale insulin is ordered ac, which is before meals; therefore, this medication
rv rv rv rv rv rv rv rv rv rv rv rv rv
must be administered first after receiving the a.m. shift report.
rv rv rv rv rv rv rv rv rv
4-Routine medications have a 1- rv rv rv rv
hour leeway before and after the scheduled time; therefore, this medication does not
rv rv rv rv rv rv rv rv rv rv rv rv r
have to be adminis- tered first.
v rv rv rv rv rv
5. The nurse is interviewing a patient who has a hearing impairment. What technique
rv rv rv rv rv rv rv rv rv rv rv rv rv
s would be most beneficial in communicating with this patient?
rv rv rv rv rv rv rv rv rv
, A) Determine the communication method he prefers.
rv rv rv rv rv rv
B) Avoid using facial and hand gestures because most hearing-
rv rv rv rv rv rv rv rv rv
impaired people find this degrading. rv rv rv rv
C) Request a sign language interpreter before meeting with him to help facilitate the
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
communication.
D) Speak loudly and with exaggerated facial movement when talking with him becau
rv rv rv rv rv rv rv rv rv rv rv rv
se this helps with lip reading. - ANSWERS--
rv rv rv rv rv rv rv
A) Determine the communication method he prefers.
rv rv rv rv rv rv
Pages: 40- rv
41 The nurse should ask the deaf person the preferred way to communicate—
rv rv rv rv rv rv rv rv rv rv rv rv
by signing, lip reading, or writing. If the person prefers lip reading, then the nurse sho
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
uld be sure to face him or her squarely and have good lighting on the nurse's face. T
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
he nurse should not exaggerate lip movements because this distorts words. Similarly
rv rv rv rv rv rv rv rv rv rv rv
, shouting distorts the reception of a hearing aid the person may wear. The nurse sh
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
ould speak slowly and should supplement his or her voice with appropriate hand ges
rv rv rv rv rv rv rv rv rv rv rv rv rv
tures or pantomime. rv rv
6. The nurse enters the client's room and realizes the 9-month-
rv rv rv rv rv rv rv rv rv rv
old infant is not breath- ing. Which interventions should the nurse implement?
rv rv rv rv rv rv rv rv rv rv rv
Prioritize the nurse's actions from first (1) to last (5).
rv rv rv rv rv rv rv rv rv rv
1. Perform cardiac compression 30:2.
rv rv rv rv
2. Check the infant's brachial pulse. 3. Administer two puffs to the infant. 4. Determin
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
e unresponsiveness.
rv
5. Open the infant's airway. - ANSWERS--Rationale
rv rv rv rv rv rv rv
Correct Answer: 4, 5, 3, 2, 1 rv rv rv rv rv rv
4. The nurse must first determine the
rv rv rv rv rv rv
infant's responsiveness by thumping the rv rv rv rv
baby's feet. rv
5. The nurse should then open the child's
rv rv rv rv rv rv rv
airway using the head-tilt chin-lift tech-
rv rv rv rv rv
nique, with care taken not to hyperextend the neck. Then the nurse should look, liste
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
n, and feel for respirations.
rv rv rv rv
3. The nurse then administers quick puffs of air while covering the child's mouth and
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
nose, preferably with a rescue mask.
rv rv rv rv rv
2. The nurse should determine whether the infant has a pulse by checking the brachi
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
al artery. rv
1. If the infant has no pulse, the nurse should begin chest compressions using two fi
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
ngers at a rate of 30:2. rv rv rv rv rv
6. The nurse is performing a health interview on a patient who has a language barrie
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
r, and no interpreter is available. Which is the best example of an appropriate questio
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
n for the nurse to ask in this situation?
rv rv rv rv rv rv rv rv
A) "Do you take medicine?"
rv rv rv rv
B) "Do you sterilize the bottles?"
rv rv rv rv rv
C) "Do you have nausea and vomiting?"
rv rv rv rv rv rv
D) "You have been taking your medicine, haven't you?" - ANSWERS--
rv rv rv rv rv rv rv rv rv rv
A) "Do you take medicine?"
rv rv rv rv
QUESTIONS AND ANSWERS
1. The nurse is working in the emergency department (ED) of a children's medical ce
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
nter. Which client should the nurse assess first?
rv rv rv rv rv rv rv
1. The 1-month-old infant who has developed colic and is crying.
rv rv rv rv rv rv rv rv rv rv
2. The 2-year-old toddler who was bitten by another child at the day-
rv rv rv rv rv rv rv rv rv rv rv rv
care center. 3. The 6-year-old school-
rv rv rv rv rv
age child who was hit by a car while riding a bicycle.
rv rv rv rv rv rv rv rv rv rv rv
4. The 14-year-old adolescent whose mother suspects her child is sexually active. -
rv rv rv rv rv rv rv rv rv rv rv rv
ANSWERS--Rationale
rv rv
Correct - 3- rv rv
The child hit by a car should be assessed first because he or she may have life-
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
threatening injuries that must be assessed and treated promptly.
rv rv rv rv rv rv rv rv rv
1. In an interview, the nurse may find it necessary to take notes to aid his or her me
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
mory later. Which statement is true regarding note-taking?
rv rv rv rv rv rv rv rv
A) Note- rv
taking may impede the nurse's observation of the patient's nonverbal behaviors.
rv rv rv rv rv rv rv rv rv rv
B) Note- rv
taking allows the patient to continue at his or her own pace as the nurse records wha
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
t is said.
rv rv
C) Note- rv
taking allows the nurse to shift attention away from the patient, resulting in an increa
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
sed comfort level. rv rv
D) Note- rv
taking allows the nurse to break eye contact with the patient, which may increase his
rv rv rv rv rv rv rv rv rv rv rv rv rv rv r
vor her level of comfort. - ANSWERS--A) Note-
rv rv rv rv rv rv rv
taking may impede the nurse's observation of the patient's nonverbal behaviors.
rv rv rv rv rv rv rv rv rv rv
Page: 31 Some use of history forms and note-
rv rv rv rv rv rv rv rv
taking may be unavoidable. But be aware that note-
rv rv rv rv rv rv rv rv
taking during the interview has disadvantages. It breaks eye contact too often, and it
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
shifts attention away from the patient, which diminishes his or her sense of importanc
rv rv rv rv rv rv rv rv rv rv rv rv rv
e. It also may interrupt the patient's narrative flow, and it impedes the observation of
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
the patient's nonverbal behavior.
rv rv rv
2. The 8-year-old client diagnosed with a vaso-
rv rv rv rv rv rv rv
occlusive sickle cell crisis is complaining of a severe headache. Which intervention s
rv rv rv rv rv rv rv rv rv rv rv rv
hould the nurse implement first?
rv rv rv rv
1. Administer 6 L of oxygen via nasal cannula.
rv rv rv rv rv rv rv rv
2. Assess the client's neurological status.
rv rv rv rv rv
3. Administer a narcotic analgesic by intravenous push (IVP). 4. Increase the client's
rv rv rv rv rv rv rv rv rv rv rv rv rv
intravenous (IV) rate. - ANSWERS--Rationale rv rv rv rv rv
,Correct - 2- rv rv
Because the client is complaining of a headache, the nurse should first rule out cere
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
brovascular accident (CVA) by assess- rv rv rv rv
ing the client's neurological status and then determine whether it is a headache that
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
can be treated with medication.
rv rv rv rv
2. During an interview, the nurse states, "You mentioned shortness of breath. Tell m
rv rv rv rv rv rv rv rv rv rv rv rv rv
e more about that." Which verbal skill is used with this statement?
rv rv rv rv rv rv rv rv rv rv rv
A) Reflection
rv
B) Facilitation
rv
C) Direct question
rv rv
D) Open-ended question - ANSWERS--D) Open-ended question
rv rv rv rv rv rv
Page: 32 The open- rv rv rv
ended question asks for narrative information. It states the topic to be discussed but
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
only in general terms. The nurse should use it to begin the interview, to introduce a n
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
ew section of questions, and whenever the person introduces a new topic.
rv rv rv rv rv rv rv rv rv rv rv
3. The 6-year-
rv rv
old client who has undergone abdominal surgery is attempting to make a pinwheel s
rv rv rv rv rv rv rv rv rv rv rv rv rv
pin by blowing on it with the nurse's assistance. The child starts crying because the p
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
inwheel won't spin. Which action should the nurse implement first?
rv rv rv rv rv rv rv rv rv
1. Praise the child for the attempt to make the pinwheel spin.
rv rv rv rv rv rv rv rv rv rv rv
2. Notify the respiratory therapist to implement incentive spirometry. 3. Encourage th
rv rv rv rv rv rv rv rv rv rv rv
e child to turn from side to side and cough.
rv rv rv rv rv rv rv rv rv
4. Demonstrate how to make the pinwheel spin by blowing on it. - ANSWERS--
rv rv rv rv rv rv rv rv rv rv rv rv rv
Rationale rv
Correct - rv
1. The nurse should always praise the child for attempts at cooperation even if the c
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
hild did not accomplish what the nurse asked.
rv rv rv rv rv rv rv
3. A nurse is taking complete health histories on all of the patients attending a wellne
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
ss workshop. On the history form, one of the written questions asks, "You don't smok
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
e, drink, or take drugs, do you?" This question is an example of:
rv rv rv rv rv rv rv rv rv rv rv rv
A) talking too much.
rv rv rv
B) using confrontation.
rv rv
C) using biased or leading questions.
rv rv rv rv rv
D) using blunt language to deal with distasteful topics. - ANSWERS--
rv rv rv rv rv rv rv rv rv rv
C) using biased or leading questions.
rv rv rv rv rv
Page: 36 This is an example of using leading or biased questions. Asking, "You don't
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
smoke, do you?" implies that one answer is "better" than another. If the person want
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
s to please someone, he or she is either forced to answer in a way corresponding to
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
their implied values or is made to feel guilty when admitting the other answer.
rv rv rv rv rv rv rv rv rv rv rv rv rv
4. The nurse is caring for clients on the pediatric medical unit. Which client should th
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
e nurse assess first?
rv rv rv
,1. The child diagnosed with type 1 diabetes who has a blood glucose level
rv rv rv rv rv rv rv rv rv rv rv rv rv
of 180 mg/dL.
rv rv
2. The child diagnosed with pneumonia who is coughing and has a temperature of
rv rv rv rv rv rv rv rv rv rv rv rv rv
100°F.
3. The child diagnosed with gastroenteritis who has a potassium (K+) level
rv rv rv rv rv rv rv rv rv rv rv
of 3.9 mEq/L.
rv rv
4. The child diagnosed with cystic fibrosis who has a pulse oximeter reading of 90%.
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
- ANSWERS--Rationale
rv rv
Correct - rv
4. A pulse oximeter reading of less than 93% is significant and indicates hypoxia, wh
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
ich is life threatening; therefore, this child should be assessed first.
rv rv rv rv rv rv rv rv rv rv
4. During an interview, a parent of a hospitalized child is sitting in an open position. A
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
s the interviewer begins to discuss his son's treatment, however, he suddenly crosse
rv rv rv rv rv rv rv rv rv rv rv rv
s his arms against his chest and crosses his legs. This would suggest that the parent
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
is:
rv
A) just changing positions.
rv rv rv
B) more comfortable in this position.
rv rv rv rv rv
C) tired and needs a break from the interview.
rv rv rv rv rv rv rv rv
D) uncomfortable talking about his son's treatment. - ANSWERS--
rv rv rv rv rv rv rv rv
D) uncomfortable talking about his son's treatment.
rv rv rv rv rv rv
Page: 37 Note the person's position. An open position with the extension of large mu
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
scle groups shows relaxation, physical comfort, and a willingness to share informatio
rv rv rv rv rv rv rv rv rv rv rv
n. A closed position with the arms and legs crossed tends to look defensive and anxi
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
ous. Note any change in posture. If a person in a relaxed position suddenly tenses, it
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv r
suggests possible discomfort with the new topic.
v rv rv rv rv rv rv
5. The nurse has received the a.m. shift report for clients on a pediatric unit. Which
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
medication should the nurse administer first? rv rv rv rv rv
1. The third dose of the aminoglycoside antibiotic to the child diagnosed with
rv rv rv rv rv rv rv rv rv rv rv rv
methicillin-resistant Staphylococcus aureus (MRSA). rv rv rv
2. The IVP steroid methylprednisolone (Solu-Medrol) to the child diagnosed with
rv rv rv rv rv rv rv rv rv rv
asthma.
3. The sliding scale insulin to the child diagnosed with type 1 diabetes mellitus.
rv rv rv rv rv rv rv rv rv rv rv rv rv
4. The stimulant methylphenidate (Ritalin) to a child diagnosed with attention
rv rv rv rv rv rv rv rv rv rv
deficit-hyperactivity disorder (ADHD). - ANSWERS--Rationale rv rv rv rv rv
Correct - 3- rv rv
Sliding scale insulin is ordered ac, which is before meals; therefore, this medication
rv rv rv rv rv rv rv rv rv rv rv rv rv
must be administered first after receiving the a.m. shift report.
rv rv rv rv rv rv rv rv rv
4-Routine medications have a 1- rv rv rv rv
hour leeway before and after the scheduled time; therefore, this medication does not
rv rv rv rv rv rv rv rv rv rv rv rv r
have to be adminis- tered first.
v rv rv rv rv rv
5. The nurse is interviewing a patient who has a hearing impairment. What technique
rv rv rv rv rv rv rv rv rv rv rv rv rv
s would be most beneficial in communicating with this patient?
rv rv rv rv rv rv rv rv rv
, A) Determine the communication method he prefers.
rv rv rv rv rv rv
B) Avoid using facial and hand gestures because most hearing-
rv rv rv rv rv rv rv rv rv
impaired people find this degrading. rv rv rv rv
C) Request a sign language interpreter before meeting with him to help facilitate the
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
communication.
D) Speak loudly and with exaggerated facial movement when talking with him becau
rv rv rv rv rv rv rv rv rv rv rv rv
se this helps with lip reading. - ANSWERS--
rv rv rv rv rv rv rv
A) Determine the communication method he prefers.
rv rv rv rv rv rv
Pages: 40- rv
41 The nurse should ask the deaf person the preferred way to communicate—
rv rv rv rv rv rv rv rv rv rv rv rv
by signing, lip reading, or writing. If the person prefers lip reading, then the nurse sho
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
uld be sure to face him or her squarely and have good lighting on the nurse's face. T
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
he nurse should not exaggerate lip movements because this distorts words. Similarly
rv rv rv rv rv rv rv rv rv rv rv
, shouting distorts the reception of a hearing aid the person may wear. The nurse sh
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
ould speak slowly and should supplement his or her voice with appropriate hand ges
rv rv rv rv rv rv rv rv rv rv rv rv rv
tures or pantomime. rv rv
6. The nurse enters the client's room and realizes the 9-month-
rv rv rv rv rv rv rv rv rv rv
old infant is not breath- ing. Which interventions should the nurse implement?
rv rv rv rv rv rv rv rv rv rv rv
Prioritize the nurse's actions from first (1) to last (5).
rv rv rv rv rv rv rv rv rv rv
1. Perform cardiac compression 30:2.
rv rv rv rv
2. Check the infant's brachial pulse. 3. Administer two puffs to the infant. 4. Determin
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
e unresponsiveness.
rv
5. Open the infant's airway. - ANSWERS--Rationale
rv rv rv rv rv rv rv
Correct Answer: 4, 5, 3, 2, 1 rv rv rv rv rv rv
4. The nurse must first determine the
rv rv rv rv rv rv
infant's responsiveness by thumping the rv rv rv rv
baby's feet. rv
5. The nurse should then open the child's
rv rv rv rv rv rv rv
airway using the head-tilt chin-lift tech-
rv rv rv rv rv
nique, with care taken not to hyperextend the neck. Then the nurse should look, liste
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
n, and feel for respirations.
rv rv rv rv
3. The nurse then administers quick puffs of air while covering the child's mouth and
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
nose, preferably with a rescue mask.
rv rv rv rv rv
2. The nurse should determine whether the infant has a pulse by checking the brachi
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
al artery. rv
1. If the infant has no pulse, the nurse should begin chest compressions using two fi
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
ngers at a rate of 30:2. rv rv rv rv rv
6. The nurse is performing a health interview on a patient who has a language barrie
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r, and no interpreter is available. Which is the best example of an appropriate questio
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n for the nurse to ask in this situation?
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A) "Do you take medicine?"
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B) "Do you sterilize the bottles?"
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C) "Do you have nausea and vomiting?"
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D) "You have been taking your medicine, haven't you?" - ANSWERS--
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A) "Do you take medicine?"
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