HESI A2 Critical Thinking Exam 2025
– Verified Questions with Correct
Answers and Rationales
Question 1
A client with chest pain is admitted to the emergency department. The nurse notes the client is
diaphoretic and reports nausea. What should the nurse do first?
A. Administer aspirin.
B. Obtain an electrocardiogram (ECG).
C. Check the client’s blood pressure.
D. Provide supplemental oxygen.
Correct Answer: D. Provide supplemental oxygen
Rationale: Chest pain with diaphoresis and nausea suggests possible myocardial infarction,
where oxygen delivery to the heart is critical. Providing supplemental oxygen is the priority to
improve oxygenation. An ECG and blood pressure are important but secondary, and aspirin
requires a provider’s order.
Question 2
A nurse is caring for a client with a fever of 39°C (102.2°F). Which intervention should the nurse
implement first?
A. Administer acetaminophen.
B. Apply a cooling blanket.
C. Encourage fluid intake.
D. Notify the provider.
Correct Answer: C. Encourage fluid intake
Rationale: Fever increases fluid loss through sweating, risking dehydration. Encouraging fluid
intake is the first non-invasive action to prevent complications. Acetaminophen and cooling
blankets require orders, and notifying the provider is not urgent for this fever level.
,Question 3
A client with diabetes reports feeling shaky and sweaty. What should the nurse do first?
A. Check the client’s blood glucose level.
B. Administer insulin.
C. Provide a high-protein snack.
D. Notify the provider.
Correct Answer: A. Check the client’s blood glucose level
Rationale: Shaking and sweating indicate possible hypoglycemia in a diabetic client. Checking
blood glucose confirms the cause and guides treatment. Administering insulin could worsen
hypoglycemia, a high-protein snack is less urgent, and notifying the provider follows assessment.
Question 4
A nurse observes a client with a new cast on their leg reporting severe pain unrelieved by
medication. What should the nurse suspect?
A. Normal postoperative pain
B. Compartment syndrome
C. Muscle strain
D. Allergic reaction to the cast
Correct Answer: B. Compartment syndrome
Rationale: Severe, unrelieved pain in a casted limb suggests compartment syndrome, a medical
emergency due to increased pressure impairing circulation. Normal pain should respond to
medication, muscle strain is unlikely, and allergic reactions typically cause skin symptoms.
Question 5
A client refuses a prescribed blood transfusion due to religious beliefs. What should the nurse
do?
A. Administer the transfusion anyway.
B. Document the refusal and inform the provider.
C. Convince the client to accept the transfusion.
D. Request a court order to proceed.
Correct Answer: B. Document the refusal and inform the provider
Rationale: Respecting patient autonomy, the nurse must document the refusal and notify the
, provider to explore alternatives. Administering against the client’s wishes is unethical,
convincing may undermine trust, and a court order is a last resort.
Question 6
A client with chronic obstructive pulmonary disease (COPD) is short of breath. Which position
should the nurse recommend?
A. Supine
B. Prone
C. Fowler’s
D. Lateral
Correct Answer: C. Fowler’s
Rationale: Fowler’s position (semi-upright) maximizes lung expansion, easing breathing in
COPD clients. Supine and prone positions can restrict breathing, and lateral is less effective for
respiratory distress.
Question 7
A nurse is preparing to administer a medication but notices the client’s name band does not
match the chart. What should the nurse do?
A. Administer the medication as ordered.
B. Verify the client’s identity with another nurse.
C. Check the client’s identity using two identifiers.
D. Assume the name band is incorrect and proceed.
Correct Answer: C. Check the client’s identity using two identifiers
Rationale: Patient safety requires verifying identity using two identifiers (e.g., name and date of
birth) to prevent medication errors. Administering without verification is unsafe, involving
another nurse is unnecessary, and assumptions risk errors.
Question 8
A client with a history of heart failure reports sudden weight gain of 4 pounds in 2 days. What
should the nurse do first?
– Verified Questions with Correct
Answers and Rationales
Question 1
A client with chest pain is admitted to the emergency department. The nurse notes the client is
diaphoretic and reports nausea. What should the nurse do first?
A. Administer aspirin.
B. Obtain an electrocardiogram (ECG).
C. Check the client’s blood pressure.
D. Provide supplemental oxygen.
Correct Answer: D. Provide supplemental oxygen
Rationale: Chest pain with diaphoresis and nausea suggests possible myocardial infarction,
where oxygen delivery to the heart is critical. Providing supplemental oxygen is the priority to
improve oxygenation. An ECG and blood pressure are important but secondary, and aspirin
requires a provider’s order.
Question 2
A nurse is caring for a client with a fever of 39°C (102.2°F). Which intervention should the nurse
implement first?
A. Administer acetaminophen.
B. Apply a cooling blanket.
C. Encourage fluid intake.
D. Notify the provider.
Correct Answer: C. Encourage fluid intake
Rationale: Fever increases fluid loss through sweating, risking dehydration. Encouraging fluid
intake is the first non-invasive action to prevent complications. Acetaminophen and cooling
blankets require orders, and notifying the provider is not urgent for this fever level.
,Question 3
A client with diabetes reports feeling shaky and sweaty. What should the nurse do first?
A. Check the client’s blood glucose level.
B. Administer insulin.
C. Provide a high-protein snack.
D. Notify the provider.
Correct Answer: A. Check the client’s blood glucose level
Rationale: Shaking and sweating indicate possible hypoglycemia in a diabetic client. Checking
blood glucose confirms the cause and guides treatment. Administering insulin could worsen
hypoglycemia, a high-protein snack is less urgent, and notifying the provider follows assessment.
Question 4
A nurse observes a client with a new cast on their leg reporting severe pain unrelieved by
medication. What should the nurse suspect?
A. Normal postoperative pain
B. Compartment syndrome
C. Muscle strain
D. Allergic reaction to the cast
Correct Answer: B. Compartment syndrome
Rationale: Severe, unrelieved pain in a casted limb suggests compartment syndrome, a medical
emergency due to increased pressure impairing circulation. Normal pain should respond to
medication, muscle strain is unlikely, and allergic reactions typically cause skin symptoms.
Question 5
A client refuses a prescribed blood transfusion due to religious beliefs. What should the nurse
do?
A. Administer the transfusion anyway.
B. Document the refusal and inform the provider.
C. Convince the client to accept the transfusion.
D. Request a court order to proceed.
Correct Answer: B. Document the refusal and inform the provider
Rationale: Respecting patient autonomy, the nurse must document the refusal and notify the
, provider to explore alternatives. Administering against the client’s wishes is unethical,
convincing may undermine trust, and a court order is a last resort.
Question 6
A client with chronic obstructive pulmonary disease (COPD) is short of breath. Which position
should the nurse recommend?
A. Supine
B. Prone
C. Fowler’s
D. Lateral
Correct Answer: C. Fowler’s
Rationale: Fowler’s position (semi-upright) maximizes lung expansion, easing breathing in
COPD clients. Supine and prone positions can restrict breathing, and lateral is less effective for
respiratory distress.
Question 7
A nurse is preparing to administer a medication but notices the client’s name band does not
match the chart. What should the nurse do?
A. Administer the medication as ordered.
B. Verify the client’s identity with another nurse.
C. Check the client’s identity using two identifiers.
D. Assume the name band is incorrect and proceed.
Correct Answer: C. Check the client’s identity using two identifiers
Rationale: Patient safety requires verifying identity using two identifiers (e.g., name and date of
birth) to prevent medication errors. Administering without verification is unsafe, involving
another nurse is unnecessary, and assumptions risk errors.
Question 8
A client with a history of heart failure reports sudden weight gain of 4 pounds in 2 days. What
should the nurse do first?
