Pagei 1i ofi 50i
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HESI A2 CRITICAL THINKING EXAM i i i i
COMPLETE i
QUESTIONS AND CORRECT ANSWERS i i i i
WITH DETAILED RATIONALES CURRENT i i i i
TESTING
SECTION 1: PRIORITY SETTING & TRIAGE (Questions 1–25) i i i i i i i i
1. The nurse is working in the emergency department (ED) of a
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children's medical center. Which client should the nurse assess first?
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A. A 1-month-old infant who has developed colic and is crying B. A 3-
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N
year-old child with a fever of 101.5°F and pulling on the left ear
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O
C. A 6-year-old child who was hit by a car and is crying loudly
i i i i i i i i i i i i i
T
D. A 12-year-old adolescent with a sprained ankle
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C
Correct answer: C. A 6-year-old child who was hit by a car and is
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O
crying loudly i i
PY
Rationale: The child hit by a car should be assessed first because they
i i i i i i i i i i i i i
may have life-threatening injuries that must be assessed and treated
i i i i i i i i i i
promptly. Trauma patients take priority over less urgent conditions. The
i i i i i i i i i i
infant with colic, the child with an ear infection, and the adolescent with a
i i i i i i i i i i i i i i
sprained ankle are stable and can wait. i i i i i i i
2. The nurse is caring for four patients on a medical-surgical unit.
i i i i i i i i i i i i
Which patient should the nurse assess first?
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A. A patient who is 2 days post-operative and requesting pain medication
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B. A patient with a new-onset of confusion and shortness of breath
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C. A patient who needs assistance with ambulation to the bathroom D. A
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patient who is requesting a glass of water i i i i i i i i
, Pagei 2i ofi 50i
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Correct answer: B. A patient with a new-onset of confusion and
i i i i i i i i i i i
shortness of breath i i i
Rationale: New-onset confusion and shortness of breath are signs of a
i i i i i i i i i i i
potentially life-threatening condition, such as hypoxia, pulmonary
i i i i i i i
embolism, or stroke. This patient requires immediate assessment. Pain
i i i i i i i i i
management, assistance with ambulation, and hydration needs are i i i i i i i i
important but not urgent. i i i i
3. The nurse is triaging patients in the emergency department. Which
i i i i i i i i i i i
patient should be seen first?
i i i i i
A. A patient with chest pain radiating to the left arm
i i i i i i i i i i
B. A patient with a laceration on the forearm that is bleeding slowly
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D
C. A patient with a fever of 101°F and a cough
i i i i i i i i i i
O
D. A patient with nausea and vomiting for 24 hours
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N
Correct answer: A. A patient with chest pain radiating to the left arm
i i i i i i i i i i i i i
O
Rationale: Chest pain radiating to the left arm is a classic symptom of
i i i i i i i i i i i i i
T
myocardial infarction (heart attack). This is a life-threatening emergency
i i i i i i i i i
requiring immediate assessment and intervention. The other patients
C
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have urgent but non-life-threatening conditions.
O
i i i i i
PY
4. A nurse on a busy medical-surgical unit has four patients
i i i i i i i i i i i
assigned. Which patient should the nurse assess first? A. A
i i i i i i i i i i
patient who is scheduled for discharge later today
i i i i i i i i
B. A patient who is complaining of a headache rated 4/10
i i i i i i i i i i
C. A patient who is 1 day post-operative with a heart rate of 120 bpm
i i i i i i i i i i i i i i
D. A patient who is requesting a sleeping pill
i i i i i i i i
Correct answer: C. A patient who is 1 day post-operative with a heart
i i i i i i i i i i i i i
rate of 120 bpm
i i i i
Rationale: A heart rate of 120 bpm in a post-operative patient may indicate
i i i i i i i i i i i i i
pain, dehydration, fever, hemorrhage, or a more serious complication. This
i i i i i i i i i i
, Pagei 3i ofi 50i
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requires immediate assessment. The other patients have stable, non-urgent
i i i i i i i i i
needs. i
5. The nurse is assessing a patient with chest pain. Which of the
i i i i i i i i i i i i i
following is the priority action? i i i i i
A. Administer pain medication i i i
B. Assess the patient's oxygen saturation i i i i i
C. Obtain a 12-lead electrocardiogram i i i i
D. Notify the healthcare provider i i i i
Correct answer: B. Assess the patient's oxygen saturation
i i i i i i i i
Rationale: The first priority in any patient with chest pain is to assess
i i i i i i i i i i i i i
oxygenation. The ABCs (Airway, Breathing, Circulation) always take
D
i i i i i i i i
priority. After assessing oxygen saturation, the nurse should apply
O
i i i i i i i i i
oxygen if needed, obtain an ECG, and notify the provider.
i i i i i i i i i i
N
6. The nurse is caring for a patient who is experiencing anaphylaxis
i i i i i i i i i i i i
O
after receiving a medication. The nurse should first:
i i i i i i i i
T
A. Administer epinephrine i i
C
B. Assess the patient's airway i i i i
O
C. Apply a tourniquet above the injection site
i i i i i i i
PY
D. Notify the healthcare provider i i i i
Correct answer: B. Assess the patient's airway
i i i i i i i
Rationale: Airway assessment is always the first priority in anaphylaxis.
i i i i i i i i i i
The nurse must first determine if the airway is patent and if the patient is
i i i i i i i i i i i i i i i
having difficulty breathing. After airway assessment, the nurse should
i i i i i i i i i
administer epinephrine and notify the provider. i i i i i i
7. The nurse is caring for a patient with a suspected stroke.
i i i i i i i i i i i i
Which of the following is the priority action?
i i i i i i i i
A. Assess the patient's blood glucose level i i i i i i
B. Obtain a CT scan of the head i i i i i i i
C. Assess the patient's airway, breathing, and circulation
i i i i i i i
, Pagei 4i ofi 50i
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D. Administer tissue plasminogen activator (tPA) i i i i i
Correct answer: C. Assess the patient's airway, breathing, and
i i i i i i i i i
circulation i
Rationale: The ABCs always take priority. A patent airway and adequate
i i i i i i i i i i i
breathing and circulation must be established before any other
i i i i i i i i i
interventions. After ensuring ABCs, the nurse should assess blood glucose,
i i i i i i i i i i
obtain a CT scan, and prepare for tPA administration if indicated.
i i i i i i i i i i i
8. The nurse is caring for a patient who is at risk for falls. Which of the
i i i i i i i i i i i i i i i i i
following interventions should the nurse implement first?
i i i i i i i
A. Place the patient in a room near the nurses' station
i i i i i i i i i i
B. Apply a fall risk bracelet
D
i i i i i
C. Complete a fall risk assessment
O
i i i i i
D. Raise the bed rails i i i i
N
Correct answer: C. Complete a fall risk assessment
i i i i i i i i
O
Rationale: The first step in fall prevention is to assess the patient's fall risk
i i i i i i i i i i i i i i
T
using a validated tool. After the assessment, the nurse can implement
i i i i i i i i i i i
C
appropriate interventions based on the patient's risk level.
i i i i i i i i
O
9. The nurse is caring for a patient who is experiencing severe pain.
PY
i i i i i i i i i i i i i
Which of the following is the priority action?
i i i i i i i i
A. Assess the patient's pain using a pain scale
i i i i i i i i
B. Administer pain medication i i i
C. Notify the healthcare provider i i i i
D. Apply a warm compress i i i i
Correct answer: A. Assess the patient's pain using a pain scale
i i i i i i i i i i i
Rationale: The first step in pain management is to assess the pain. The
i i i i i i i i i i i i i
nurse should use a pain scale to assess the severity, location, quality, and
i i i i i i i i i i i i i
characteristics of the pain. After assessment, the nurse can implement i i i i i i i i i i
appropriate interventions. i i
i
HESI A2 CRITICAL THINKING EXAM i i i i
COMPLETE i
QUESTIONS AND CORRECT ANSWERS i i i i
WITH DETAILED RATIONALES CURRENT i i i i
TESTING
SECTION 1: PRIORITY SETTING & TRIAGE (Questions 1–25) i i i i i i i i
1. The nurse is working in the emergency department (ED) of a
D
i i i i i i i i i i i i
children's medical center. Which client should the nurse assess first?
O
i i i i i i i i i i
A. A 1-month-old infant who has developed colic and is crying B. A 3-
i i i i i i i i i i i i i
N
year-old child with a fever of 101.5°F and pulling on the left ear
i i i i i i i i i i i i i
O
C. A 6-year-old child who was hit by a car and is crying loudly
i i i i i i i i i i i i i
T
D. A 12-year-old adolescent with a sprained ankle
i i i i i i i
C
Correct answer: C. A 6-year-old child who was hit by a car and is
i i i i i i i i i i i i i i
O
crying loudly i i
PY
Rationale: The child hit by a car should be assessed first because they
i i i i i i i i i i i i i
may have life-threatening injuries that must be assessed and treated
i i i i i i i i i i
promptly. Trauma patients take priority over less urgent conditions. The
i i i i i i i i i i
infant with colic, the child with an ear infection, and the adolescent with a
i i i i i i i i i i i i i i
sprained ankle are stable and can wait. i i i i i i i
2. The nurse is caring for four patients on a medical-surgical unit.
i i i i i i i i i i i i
Which patient should the nurse assess first?
i i i i i i i
A. A patient who is 2 days post-operative and requesting pain medication
i i i i i i i i i i i
B. A patient with a new-onset of confusion and shortness of breath
i i i i i i i i i i i
C. A patient who needs assistance with ambulation to the bathroom D. A
i i i i i i i i i i i i
patient who is requesting a glass of water i i i i i i i i
, Pagei 2i ofi 50i
i
Correct answer: B. A patient with a new-onset of confusion and
i i i i i i i i i i i
shortness of breath i i i
Rationale: New-onset confusion and shortness of breath are signs of a
i i i i i i i i i i i
potentially life-threatening condition, such as hypoxia, pulmonary
i i i i i i i
embolism, or stroke. This patient requires immediate assessment. Pain
i i i i i i i i i
management, assistance with ambulation, and hydration needs are i i i i i i i i
important but not urgent. i i i i
3. The nurse is triaging patients in the emergency department. Which
i i i i i i i i i i i
patient should be seen first?
i i i i i
A. A patient with chest pain radiating to the left arm
i i i i i i i i i i
B. A patient with a laceration on the forearm that is bleeding slowly
i i i i i i i i i i i i
D
C. A patient with a fever of 101°F and a cough
i i i i i i i i i i
O
D. A patient with nausea and vomiting for 24 hours
i i i i i i i i i
N
Correct answer: A. A patient with chest pain radiating to the left arm
i i i i i i i i i i i i i
O
Rationale: Chest pain radiating to the left arm is a classic symptom of
i i i i i i i i i i i i i
T
myocardial infarction (heart attack). This is a life-threatening emergency
i i i i i i i i i
requiring immediate assessment and intervention. The other patients
C
i i i i i i i i
have urgent but non-life-threatening conditions.
O
i i i i i
PY
4. A nurse on a busy medical-surgical unit has four patients
i i i i i i i i i i i
assigned. Which patient should the nurse assess first? A. A
i i i i i i i i i i
patient who is scheduled for discharge later today
i i i i i i i i
B. A patient who is complaining of a headache rated 4/10
i i i i i i i i i i
C. A patient who is 1 day post-operative with a heart rate of 120 bpm
i i i i i i i i i i i i i i
D. A patient who is requesting a sleeping pill
i i i i i i i i
Correct answer: C. A patient who is 1 day post-operative with a heart
i i i i i i i i i i i i i
rate of 120 bpm
i i i i
Rationale: A heart rate of 120 bpm in a post-operative patient may indicate
i i i i i i i i i i i i i
pain, dehydration, fever, hemorrhage, or a more serious complication. This
i i i i i i i i i i
, Pagei 3i ofi 50i
i
requires immediate assessment. The other patients have stable, non-urgent
i i i i i i i i i
needs. i
5. The nurse is assessing a patient with chest pain. Which of the
i i i i i i i i i i i i i
following is the priority action? i i i i i
A. Administer pain medication i i i
B. Assess the patient's oxygen saturation i i i i i
C. Obtain a 12-lead electrocardiogram i i i i
D. Notify the healthcare provider i i i i
Correct answer: B. Assess the patient's oxygen saturation
i i i i i i i i
Rationale: The first priority in any patient with chest pain is to assess
i i i i i i i i i i i i i
oxygenation. The ABCs (Airway, Breathing, Circulation) always take
D
i i i i i i i i
priority. After assessing oxygen saturation, the nurse should apply
O
i i i i i i i i i
oxygen if needed, obtain an ECG, and notify the provider.
i i i i i i i i i i
N
6. The nurse is caring for a patient who is experiencing anaphylaxis
i i i i i i i i i i i i
O
after receiving a medication. The nurse should first:
i i i i i i i i
T
A. Administer epinephrine i i
C
B. Assess the patient's airway i i i i
O
C. Apply a tourniquet above the injection site
i i i i i i i
PY
D. Notify the healthcare provider i i i i
Correct answer: B. Assess the patient's airway
i i i i i i i
Rationale: Airway assessment is always the first priority in anaphylaxis.
i i i i i i i i i i
The nurse must first determine if the airway is patent and if the patient is
i i i i i i i i i i i i i i i
having difficulty breathing. After airway assessment, the nurse should
i i i i i i i i i
administer epinephrine and notify the provider. i i i i i i
7. The nurse is caring for a patient with a suspected stroke.
i i i i i i i i i i i i
Which of the following is the priority action?
i i i i i i i i
A. Assess the patient's blood glucose level i i i i i i
B. Obtain a CT scan of the head i i i i i i i
C. Assess the patient's airway, breathing, and circulation
i i i i i i i
, Pagei 4i ofi 50i
i
D. Administer tissue plasminogen activator (tPA) i i i i i
Correct answer: C. Assess the patient's airway, breathing, and
i i i i i i i i i
circulation i
Rationale: The ABCs always take priority. A patent airway and adequate
i i i i i i i i i i i
breathing and circulation must be established before any other
i i i i i i i i i
interventions. After ensuring ABCs, the nurse should assess blood glucose,
i i i i i i i i i i
obtain a CT scan, and prepare for tPA administration if indicated.
i i i i i i i i i i i
8. The nurse is caring for a patient who is at risk for falls. Which of the
i i i i i i i i i i i i i i i i i
following interventions should the nurse implement first?
i i i i i i i
A. Place the patient in a room near the nurses' station
i i i i i i i i i i
B. Apply a fall risk bracelet
D
i i i i i
C. Complete a fall risk assessment
O
i i i i i
D. Raise the bed rails i i i i
N
Correct answer: C. Complete a fall risk assessment
i i i i i i i i
O
Rationale: The first step in fall prevention is to assess the patient's fall risk
i i i i i i i i i i i i i i
T
using a validated tool. After the assessment, the nurse can implement
i i i i i i i i i i i
C
appropriate interventions based on the patient's risk level.
i i i i i i i i
O
9. The nurse is caring for a patient who is experiencing severe pain.
PY
i i i i i i i i i i i i i
Which of the following is the priority action?
i i i i i i i i
A. Assess the patient's pain using a pain scale
i i i i i i i i
B. Administer pain medication i i i
C. Notify the healthcare provider i i i i
D. Apply a warm compress i i i i
Correct answer: A. Assess the patient's pain using a pain scale
i i i i i i i i i i i
Rationale: The first step in pain management is to assess the pain. The
i i i i i i i i i i i i i
nurse should use a pain scale to assess the severity, location, quality, and
i i i i i i i i i i i i i
characteristics of the pain. After assessment, the nurse can implement i i i i i i i i i i
appropriate interventions. i i
