HESI A2 Critical Thinking LATEST 2021 with Highlighted Answers

1. The Patient: A 65-year- old male. The Situation: The family brings the patient to the emergency room because he just took an entire bottle of pills. The Question: What action should the nurse take first? Answer – Determine the patient’s level of consciousness. 2. The Patient: An 80 year-old male who has used continuous oxygen for the past three years. The Situation: While making a home visit, the wife tells the nurse that her husband was doing well on 2 litres of oxygen per minute until late last night when he developed severe shortness of breath on the way to the bathroom. The Question: What action should the nurse take first? Answer – Assess the patient’s oxygen saturation by pulse oximeter. 3. The Patient: A 41-year-old male. The Situation: The patient is complaining of severe stomach pain and states that he has been “vomiting all the time.” The Question: What should the nurse do first? Answer – Administer a prescribed pain medication. 4. The Patient: The wife of a wealthy owner of the town’s bank. The Situation: The patient and her husband arrive on the unit. While orienting the patient to the hospital room, the nurse notices that the patient has placed a large amount of cash and some expensive earrings in the drawer of the bedside table. The Question: What is the best action for the nurse to take? Answer – Advise the patient to have her husband take the items home when he leaves. 5. The Patient: A 45-year-old female who is 5’ 2” tall, weighs 200 pounds, and has smoked since age 21. The Situation: The patient comes to the clinic with a complaint of “leg pain.” The Question: It is most important for the nurse to obtain information about which previous occurrence? Answer – A previous blood clot in the leg. 6. The Patient: A 61-year-old female. The Situation: The patient has a fever of unknown origin. The nurse administered a fever-reducing medication 30 minutes ago. At this time there has been no decrease in the patient’s fever. The Question: What action would be best for the nurse to take? Answer – Sponge the patient with cool water. 7. The Patient: A 70-year-old male who is relatively healthy. The Situation: A liquid mediation is prescribed for this patient. The Question: Prior to administering the prescribed medication, what intervention has the highest priority? Answer – Determine if the patient is allergic to the medication. 8. The Patient: A fifty-eight-year-old female. The Situation: While the nurse is offering the patient her morning medications, she tells the nurse that she does not recall ever taking a pill that was pink-colored. The Question: What should the nurse do in response to this patient’s comment? Answer – Withhold the mediation until the patient’s prescription is verify. 9. The Patients: 1. A 63-year-old with a burn on the left lower leg who is complaining of pain. 2. A 45-year-old with pneumonia, complaining of shortness of breath. 3. A 31-year-old with abdominal pain who has just vomited blood. 4. An 88-year-old who has right-sided paralysis and wants to be helped to the bathroom immediately. The Situation: The nurse is caring for these patients. The Question: Who should the nurse see first? Answer – The 45-years old with pneumonia and shortness of breath. 10. The Patients: 1. A 13-year-old female with a kidney infection who reports that there is “lots of blood” in her urine. 2. An 18-year-old male with acute alcohol poisoning who is seeing “bugs on the walls.” 3. A 21-year-old female with inflammatory bowel disease who has soaked a dressing three hours after surgery. 4. A 25-year old male who is sobbing in his room after being told that he has testicular cancer. The Situation: The nurse is caring for these four patients. The Question: Who should the nurse see first