Hesi A2 Critical Thinking
The Situation: The family brings the patient to the emergency room
because he just took an entire bottle of pills.The Question: What Answer - Determine the patient's level of consciousness.
action should the nurse take first?
The Patient: An 80 year-old male who has used continuous oxy-
gen 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 Answer - Assess the patient's oxygen saturation by pulse oximeter.
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?
The Patient: A 41-year-old male.The Situation: The patient is
complaining of severe stomach pain and states that he has been
Answer - Administer a prescribed pain medication.
"vomiting all the time."The Question: What should the nurse do
first?
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 Answer - Advise the patient to have her husband take the items
the patient has placed a large amount of cash and some expen- home when he leaves.
sive earrings in the drawer of the bedside table.
The Question: What is the best action for the nurse to take?
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 Answer - A previous blood clot in the leg.
is most important for the nurse to obtain information about which
previous occurrence?
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 de- Answer - Sponge the patient with cool water.
crease in the patient's fever.The Question: What action would be
best for the nurse to take?
The Patient: A 70-year-old male who is relatively healthy.The
Situation: A liquid mediation is prescribed for this patient.The
Answer - Determine if the patient is allergic to the medication.
Question: Prior to administering the prescribed medication, what
intervention has the highest priority?
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 Answer - Withhold the mediation until the patient's prescription is
pink-colored.The Question: What should the nurse do in response verify.
to this patient's comment?
The Patients:
A 63-year-old with a burn on the left lower leg who is complaining
of pain.
A 45-year-old with pneumonia, complaining of shortness of
breath.
Answer - The 45-years old with pneumonia and shortness of
A 31-year-old with abdominal pain who has just vomited blood.
breath.
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?
The Patients:
A 13-year-old female with a kidney infection who reports that there
is "lots of
blood" in her urine. Answer - The 21-years old who is three hours postoperative and
An 18-year-old male with acute alcohol poisoning who is seeing has a soaked
"bugs on the dressing.
walls."
A 21-year-old female with inflammatory bowel disease who has
soaked a dressing
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, Hesi A2 Critical Thinking
three hours after surgery.
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?
The Patients:
A 42-year-old with diabetes who is blind and is asking to get up
and moved to a
chair.
An 88-year-old with lower body paralysis who wants to be turned
in bed.
A 17-year-old with asthma who smokes and has been in the Answer - The 17-year old with asthma who may be smoking in the
bathroom for 30 bathroom.
minutes.
A 55-year-old with cardiac disease who tells the nurse, "Get the
TV fixed or I am
leaving this place."
The Situation: The nurse is caring for these four patients. The
Question: Which patient should the nurse see first?
The Patient: An elderly female accompanied by her middle-aged
son.The Situation: The patient is being discharged after 15-day
Answer - Sincerely thank the son, and share the candy with all
stay on the medical unit, and the son offers the nurse a box
staff member on the
of candy as a gesture of thanks for caring for his mother.The
unit.
Question: What should the nurse do in response to the offer of
this gift?
The Patient: A 25-year-old female who has smoked since age
12.The Situation: The patient is complaining of "skipped heart Answer - Call for assistance if she feels weak or dizzy when getting
beats."The Question: Which instruction is most important for the out of bed.
nurse to provide this patient?
The Patient: A frail 88-year-old male who has recently become
slightly confused.The Situation: The nurse is making a home visit
and assesses the safety features of the home environment.The Answer - Eliminate any throw rugs from floor.
Question: Which suggestion would be most important for the
nurse to provide the family?
The Patient: A 55-year-old female with a family history of hyper-
tension.The Situation: The patient is concerned about her health The Question: What action would be best for the nurse to take?
and states, "I have had severe headaches for the last six months. Answer - Ask the patient about the frequency, timing and quality
I think I might have high blood pressure." The nurse determines of her headaches.
that the woman's blood pressure is 138/86 (high normal).
The Patient: A 35-year-old female with a history of asthma.The
Situation: The patient has been using a steroid inhaler because
she is short of breath. However, she states that her shortness of Answer - Method of using the inhaler.
breath is "no better."The Question: What is the most important
information for the nurse to obtain?
The Patient: An older confused male.The Situation: At 3 a.m. the
patient, who thinks he is in the bathroom, defecates in the bed.
Answer - Ask a nursing assistant to go to another unit and borrow
The bed needs to be changed. However, there are no bed sheets
linen.
on the nursing unit.The Question: What action should the nurse
take first?
The Patient: A 25-year-old female hospitalized for anorexia.The
Situation: The charge nurse denies the patient permission to pass
Answer - Treatment protocol for anorexics mandates that they
dinner trays. The Question: What is the most important reason
avoid preoccupation with food.
for the nurse to deny this anorexic patient permission to pass the
dinner trays?
The Patient: A 75-year-old male who had a heart attack four
years ago.The Situation: The patient tells the nurse, "Even though
Answer - Auscultate all lung fields
I stopped smoking 10 years ago, I have a terrible cough."The
Question: What action should the nurse take first?
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The Situation: The family brings the patient to the emergency room
because he just took an entire bottle of pills.The Question: What Answer - Determine the patient's level of consciousness.
action should the nurse take first?
The Patient: An 80 year-old male who has used continuous oxy-
gen 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 Answer - Assess the patient's oxygen saturation by pulse oximeter.
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?
The Patient: A 41-year-old male.The Situation: The patient is
complaining of severe stomach pain and states that he has been
Answer - Administer a prescribed pain medication.
"vomiting all the time."The Question: What should the nurse do
first?
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 Answer - Advise the patient to have her husband take the items
the patient has placed a large amount of cash and some expen- home when he leaves.
sive earrings in the drawer of the bedside table.
The Question: What is the best action for the nurse to take?
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 Answer - A previous blood clot in the leg.
is most important for the nurse to obtain information about which
previous occurrence?
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 de- Answer - Sponge the patient with cool water.
crease in the patient's fever.The Question: What action would be
best for the nurse to take?
The Patient: A 70-year-old male who is relatively healthy.The
Situation: A liquid mediation is prescribed for this patient.The
Answer - Determine if the patient is allergic to the medication.
Question: Prior to administering the prescribed medication, what
intervention has the highest priority?
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 Answer - Withhold the mediation until the patient's prescription is
pink-colored.The Question: What should the nurse do in response verify.
to this patient's comment?
The Patients:
A 63-year-old with a burn on the left lower leg who is complaining
of pain.
A 45-year-old with pneumonia, complaining of shortness of
breath.
Answer - The 45-years old with pneumonia and shortness of
A 31-year-old with abdominal pain who has just vomited blood.
breath.
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?
The Patients:
A 13-year-old female with a kidney infection who reports that there
is "lots of
blood" in her urine. Answer - The 21-years old who is three hours postoperative and
An 18-year-old male with acute alcohol poisoning who is seeing has a soaked
"bugs on the dressing.
walls."
A 21-year-old female with inflammatory bowel disease who has
soaked a dressing
1/7
, Hesi A2 Critical Thinking
three hours after surgery.
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?
The Patients:
A 42-year-old with diabetes who is blind and is asking to get up
and moved to a
chair.
An 88-year-old with lower body paralysis who wants to be turned
in bed.
A 17-year-old with asthma who smokes and has been in the Answer - The 17-year old with asthma who may be smoking in the
bathroom for 30 bathroom.
minutes.
A 55-year-old with cardiac disease who tells the nurse, "Get the
TV fixed or I am
leaving this place."
The Situation: The nurse is caring for these four patients. The
Question: Which patient should the nurse see first?
The Patient: An elderly female accompanied by her middle-aged
son.The Situation: The patient is being discharged after 15-day
Answer - Sincerely thank the son, and share the candy with all
stay on the medical unit, and the son offers the nurse a box
staff member on the
of candy as a gesture of thanks for caring for his mother.The
unit.
Question: What should the nurse do in response to the offer of
this gift?
The Patient: A 25-year-old female who has smoked since age
12.The Situation: The patient is complaining of "skipped heart Answer - Call for assistance if she feels weak or dizzy when getting
beats."The Question: Which instruction is most important for the out of bed.
nurse to provide this patient?
The Patient: A frail 88-year-old male who has recently become
slightly confused.The Situation: The nurse is making a home visit
and assesses the safety features of the home environment.The Answer - Eliminate any throw rugs from floor.
Question: Which suggestion would be most important for the
nurse to provide the family?
The Patient: A 55-year-old female with a family history of hyper-
tension.The Situation: The patient is concerned about her health The Question: What action would be best for the nurse to take?
and states, "I have had severe headaches for the last six months. Answer - Ask the patient about the frequency, timing and quality
I think I might have high blood pressure." The nurse determines of her headaches.
that the woman's blood pressure is 138/86 (high normal).
The Patient: A 35-year-old female with a history of asthma.The
Situation: The patient has been using a steroid inhaler because
she is short of breath. However, she states that her shortness of Answer - Method of using the inhaler.
breath is "no better."The Question: What is the most important
information for the nurse to obtain?
The Patient: An older confused male.The Situation: At 3 a.m. the
patient, who thinks he is in the bathroom, defecates in the bed.
Answer - Ask a nursing assistant to go to another unit and borrow
The bed needs to be changed. However, there are no bed sheets
linen.
on the nursing unit.The Question: What action should the nurse
take first?
The Patient: A 25-year-old female hospitalized for anorexia.The
Situation: The charge nurse denies the patient permission to pass
Answer - Treatment protocol for anorexics mandates that they
dinner trays. The Question: What is the most important reason
avoid preoccupation with food.
for the nurse to deny this anorexic patient permission to pass the
dinner trays?
The Patient: A 75-year-old male who had a heart attack four
years ago.The Situation: The patient tells the nurse, "Even though
Answer - Auscultate all lung fields
I stopped smoking 10 years ago, I have a terrible cough."The
Question: What action should the nurse take first?
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