HESI A2 Critical Thinking
Exam 2025 – Verified
Questions and Correct
Answers with Rationales
Question 1: Prioritization
A nurse is caring for four clients. Which client should the nurse assess first?
A. A client with a blood pressure of 122/80 mmHg, reporting mild headache.
B. A client with chest pain and diaphoresis.
C. A client with a fever of 100.4°F, requesting water.
D. A client with a scheduled dressing change due in 30 minutes.
Correct Answer: B
Rationale: Chest pain and diaphoresis suggest a potential cardiac emergency, such as
myocardial infarction, which is life-threatening and requires immediate assessment. Option B is
the priority. A mild headache with normal blood pressure (A), a low-grade fever (C), and a
scheduled dressing change (D) are less urgent.
Question 2: Clinical Judgment
A client with diabetes reports feeling shaky and sweaty. What is the nurse’s first action?
A. Administer insulin as prescribed.
B. Check the client’s blood glucose level.
C. Offer the client a snack.
D. Notify the healthcare provider.
Correct Answer: B
Rationale: Shaking and sweating indicate possible hypoglycemia. Checking the blood glucose
level (B) confirms the diagnosis and guides treatment. Administering insulin (A) could worsen
hypoglycemia. Offering a snack (C) is premature without confirmation. Notifying the provider
(D) is secondary to assessment.
Question 3: Ethical Decision-Making
,A client refuses a blood transfusion due to religious beliefs. What is the nurse’s best action?
A. Administer the transfusion to save the client’s life.
B. Respect the client’s decision and inform the healthcare provider.
C. Convince the client to accept the transfusion.
D. Document the refusal and proceed with the transfusion.
Correct Answer: B
Rationale: Respecting the client’s autonomy is an ethical priority. Option B upholds the client’s
rights and ensures provider awareness for alternative treatments. Administering (A) or
proceeding with (D) the transfusion violates autonomy. Convincing the client (C) disregards
their beliefs.
Question 4: Problem-Solving
A client with a tracheostomy is coughing and has difficulty breathing. What is the nurse’s
priority action?
A. Administer oxygen via nasal cannula.
B. Suction the tracheostomy as needed.
C. Change the tracheostomy tube.
D. Encourage deep breathing exercises.
Correct Answer: B
Rationale: Coughing and difficulty breathing suggest a tracheostomy obstruction. Suctioning
(B) clears the airway, addressing the immediate issue. Nasal cannula oxygen (A) is ineffective
for tracheostomy clients. Changing the tube (C) is unnecessary without assessment. Deep
breathing (D) is impractical during airway obstruction.
Question 5: Prioritization (Select All That Apply)
Which clients require immediate attention from the nurse? (Select all that apply.)
A. A client with a respiratory rate of 32 breaths/min and oxygen saturation of 88%.
B. A client with a scheduled medication due in 10 minutes.
C. A client reporting sudden numbness in one arm.
D. A client requesting a blanket for comfort.
E. A client with a blood pressure of 180/100 mmHg and chest pain.
Correct Answers: A, C, E
Rationale: A respiratory rate of 32 and low oxygen saturation (A), sudden numbness (C,
possible stroke), and severe hypertension with chest pain (E, possible cardiac event) indicate
urgent conditions requiring immediate assessment. A scheduled medication (B) and a blanket
request (D) are non-urgent.
, Question 6: Clinical Judgment
A client post-appendectomy reports severe abdominal pain despite pain medication. What is the
nurse’s first action?
A. Administer additional pain medication.
B. Assess the client’s pain and vital signs.
C. Reassure the client that pain is expected.
D. Notify the surgeon immediately.
Correct Answer: B
Rationale: Severe pain post-surgery may indicate complications (e.g., infection, bleeding).
Assessing pain and vital signs (B) provides data to guide further action. Additional medication
(A) requires assessment first. Reassurance (C) may dismiss a serious issue. Notifying the
surgeon (D) is secondary to assessment.
Question 7: Ethical Decision-Making
A client’s family requests withholding a terminal diagnosis from the client. What is the nurse’s
best response?
A. Agree to withhold the information.
B. Discuss the request with the healthcare provider and client.
C. Inform the client of the diagnosis immediately.
D. Document the family’s request and ignore it.
Correct Answer: B
Rationale: The nurse must balance client autonomy and family concerns. Discussing with the
provider and client (B) ensures ethical decision-making. Withholding (A) or disclosing (C)
without discussion violates autonomy or collaboration. Ignoring the request (D) avoids
addressing the issue.
Question 8: Problem-Solving
A client with a history of heart failure gains 5 pounds in 2 days. What is the nurse’s priority
action?
A. Encourage a low-sodium diet.
B. Assess for signs of fluid overload.
C. Administer a diuretic as prescribed.
D. Weigh the client again to confirm.
Correct Answer: B
Rationale: Rapid weight gain in heart failure suggests fluid overload, which can lead to
pulmonary edema. Assessing for symptoms like edema or dyspnea (B) is the priority. Dietary
changes (A) are supportive but secondary. Administering a diuretic (C) requires assessment. Re-
weighing (D) delays intervention.
Exam 2025 – Verified
Questions and Correct
Answers with Rationales
Question 1: Prioritization
A nurse is caring for four clients. Which client should the nurse assess first?
A. A client with a blood pressure of 122/80 mmHg, reporting mild headache.
B. A client with chest pain and diaphoresis.
C. A client with a fever of 100.4°F, requesting water.
D. A client with a scheduled dressing change due in 30 minutes.
Correct Answer: B
Rationale: Chest pain and diaphoresis suggest a potential cardiac emergency, such as
myocardial infarction, which is life-threatening and requires immediate assessment. Option B is
the priority. A mild headache with normal blood pressure (A), a low-grade fever (C), and a
scheduled dressing change (D) are less urgent.
Question 2: Clinical Judgment
A client with diabetes reports feeling shaky and sweaty. What is the nurse’s first action?
A. Administer insulin as prescribed.
B. Check the client’s blood glucose level.
C. Offer the client a snack.
D. Notify the healthcare provider.
Correct Answer: B
Rationale: Shaking and sweating indicate possible hypoglycemia. Checking the blood glucose
level (B) confirms the diagnosis and guides treatment. Administering insulin (A) could worsen
hypoglycemia. Offering a snack (C) is premature without confirmation. Notifying the provider
(D) is secondary to assessment.
Question 3: Ethical Decision-Making
,A client refuses a blood transfusion due to religious beliefs. What is the nurse’s best action?
A. Administer the transfusion to save the client’s life.
B. Respect the client’s decision and inform the healthcare provider.
C. Convince the client to accept the transfusion.
D. Document the refusal and proceed with the transfusion.
Correct Answer: B
Rationale: Respecting the client’s autonomy is an ethical priority. Option B upholds the client’s
rights and ensures provider awareness for alternative treatments. Administering (A) or
proceeding with (D) the transfusion violates autonomy. Convincing the client (C) disregards
their beliefs.
Question 4: Problem-Solving
A client with a tracheostomy is coughing and has difficulty breathing. What is the nurse’s
priority action?
A. Administer oxygen via nasal cannula.
B. Suction the tracheostomy as needed.
C. Change the tracheostomy tube.
D. Encourage deep breathing exercises.
Correct Answer: B
Rationale: Coughing and difficulty breathing suggest a tracheostomy obstruction. Suctioning
(B) clears the airway, addressing the immediate issue. Nasal cannula oxygen (A) is ineffective
for tracheostomy clients. Changing the tube (C) is unnecessary without assessment. Deep
breathing (D) is impractical during airway obstruction.
Question 5: Prioritization (Select All That Apply)
Which clients require immediate attention from the nurse? (Select all that apply.)
A. A client with a respiratory rate of 32 breaths/min and oxygen saturation of 88%.
B. A client with a scheduled medication due in 10 minutes.
C. A client reporting sudden numbness in one arm.
D. A client requesting a blanket for comfort.
E. A client with a blood pressure of 180/100 mmHg and chest pain.
Correct Answers: A, C, E
Rationale: A respiratory rate of 32 and low oxygen saturation (A), sudden numbness (C,
possible stroke), and severe hypertension with chest pain (E, possible cardiac event) indicate
urgent conditions requiring immediate assessment. A scheduled medication (B) and a blanket
request (D) are non-urgent.
, Question 6: Clinical Judgment
A client post-appendectomy reports severe abdominal pain despite pain medication. What is the
nurse’s first action?
A. Administer additional pain medication.
B. Assess the client’s pain and vital signs.
C. Reassure the client that pain is expected.
D. Notify the surgeon immediately.
Correct Answer: B
Rationale: Severe pain post-surgery may indicate complications (e.g., infection, bleeding).
Assessing pain and vital signs (B) provides data to guide further action. Additional medication
(A) requires assessment first. Reassurance (C) may dismiss a serious issue. Notifying the
surgeon (D) is secondary to assessment.
Question 7: Ethical Decision-Making
A client’s family requests withholding a terminal diagnosis from the client. What is the nurse’s
best response?
A. Agree to withhold the information.
B. Discuss the request with the healthcare provider and client.
C. Inform the client of the diagnosis immediately.
D. Document the family’s request and ignore it.
Correct Answer: B
Rationale: The nurse must balance client autonomy and family concerns. Discussing with the
provider and client (B) ensures ethical decision-making. Withholding (A) or disclosing (C)
without discussion violates autonomy or collaboration. Ignoring the request (D) avoids
addressing the issue.
Question 8: Problem-Solving
A client with a history of heart failure gains 5 pounds in 2 days. What is the nurse’s priority
action?
A. Encourage a low-sodium diet.
B. Assess for signs of fluid overload.
C. Administer a diuretic as prescribed.
D. Weigh the client again to confirm.
Correct Answer: B
Rationale: Rapid weight gain in heart failure suggests fluid overload, which can lead to
pulmonary edema. Assessing for symptoms like edema or dyspnea (B) is the priority. Dietary
changes (A) are supportive but secondary. Administering a diuretic (C) requires assessment. Re-
weighing (D) delays intervention.
