Hesi Critical Thinking {2020} | Hesi Critical Thinking A+

Hesi Critical Thinking A+ 1. The nurse is working in the emergency department (ED) of a children's medical center. Which client should the nurse assess first? Correct - 3-The child hit by a car should be assessed first because he or she may have life- threatening injuries that must be assessed and treated promptly. 2. The 8-year-old client diagnosed with a vaso-occlusive sickle cell crisis is complaining of a severe headache. Which intervention should the nurse implement first? Correct - 2-Because the client is complaining of a headache, the nurse should first rule out cerebrovascular accident (CVA) by assess- ing the client's neurological status and then determine whether it is a headache that can be treated with medication. 3. The 6-year-old client who has undergone abdominal surgery is attempting to make a pinwheel spin by blowing on it with the nurse's assistance. The child starts crying because the pinwheel won't spin. Which action should the nurse implement first? Correct -1. The nurse should always praise the child for attempts at cooperation even if the child did not accomplish what the nurse asked. 4. The nurse is caring for clients on the pediatric medical unit. Which client should the nurse assess first? Correct - 4. A pulse oximeter reading of less than 93% is significant and indicates hypoxia, which is life threatening; therefore, this child should be assessed first. 5. The nurse has received the a.m. shift report for clients on a pediatric unit. Which medication should the nurse administer first? Correct - 3-Sliding scale insulin is ordered ac, which is before meals; therefore, this medication must be administered first after receiving the a.m. shift report. 4-Routine medications have a 1-hour leeway before and after the scheduled time; therefore, this medication does not have to be adminis- tered first. 6. A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure? D. Reactions to previous hospitalizations Rationale Assess how the child reacted to hospitalization and any complications. If the child reacted poorly, he or she may be afraid now and will need special preparation for the examination that is to follow. The other items are not significant for the procedure 7. A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the nurse do first when beginning the examination? ) Auscultate the lungs and heart while the infant is still sleeping. Rationale When the infant is quiet or sleeping is an ideal time to assess the cardiac, respiratory, and abdominal systems. Assessment of the eye, ear, nose, and throat are invasive procedures and should be performed at the end of the examination. 6. The nurse enters the client's room and realizes the 9-month-old infant is not breath- ing. Which interventions should the nurse implement? Prioritize the nurse's actions from first (1) to last (5). Rationale Correct Answer: 4, 5, 3, 2, 1 4. The nurse must first determine the infant's responsiveness by thumping the baby's feet. 5. The nurse should then open the child's airway using the head-tilt chin-lift tech- nique, with care taken not to hyperextend the neck. Then the nurse should look, listen, and feel for respirations. 3. The nurse then administers quick puffs of air while covering the child's mouth and nose, preferably with a rescue mask. 2. The nurse should determine whether the infant has a pulse by checking the brachial artery. 1. If the infant has no pulse, the nurse should begin chest compressions using two fingers at a rate of 30:2. 7. The 3-year-old client has been admitted to the pediatric unit. Which task should the nurse instruct the unlicensed assistive personnel (UAP) to perform first? Correct - 1.The first intervention after the child is ad- mitted to the unit is to orient the parents and child to the room, the call system, and the hospital rules, such as not leaving the child alone in the room. 8. The clinic nurse is preparing to administer an intramuscular (IM) injection to the 2-year-old toddler. Which intervention should the nurse implement first? Correct - 2-The nurse must explain any procedure in words the child can understand. It does not matter how old the child is. . The nurse is writing a care plan for the 5-year-old child diagnosed with gastroenteritis. Which client problem is priority? Correct - 2-The child diagnosed with gastroenteritis is at high risk for hypovolemic shock resulting from vomiting and diarrhea; therefore, maintaining fluid and elec- trolyte homeostasis is priority. 10. Which data would warrant immediate intervention from the pediatric nurse? 1. Proteinuria for the child diagnosed with nephrotic syndrome. Correct - 3-Drooling indicates the child is having trouble swallowing, and the epiglottis is at risk of completely occluding the air- way. This warrants immediate interven- tion. The nurse should notify the HCP and obtain an emergency tracheostomy tray for the bedside. 11. Which client should the pediatric nurse assess first after receiving the a.m. shift report? 4. The 13-month-old child diagnosed with diarrhea who has sunken eyeballs and decreased urine output. Rationale Correct - 4. Sunken eyeballs and decreased urine out- put are signs of dehydration, which is a life-threatening complication of diarrhea; therefore, this child should be assessed first. 12. The pediatric clinic nurse is triaging telephone calls. Which client's parent should the nurse call first? 1. The 4-month-old child who had immunizations yesterday and the parent is report- ing a high-pitched cry and a 103°F fever. Correct 1-A high fever and high-pitched crying may indicate a reaction to the immunizations; therefore, this parent needs to be called first to bring the child to the clinic. 13. The parent of a 12-year-old male child with a left below-the-knee cast calls the pedi- atric clinic nurse and tells the nurse, "My son's foot is cold and he told me it feels like his foot is asleep." Which action should the nurse implement first? 3. Instruct the parent to elevate the left leg on two pillows. Correct - 3. The nurse should first take care of the client's body by having the parent elevate the left leg. 14. Which child requires the nurse to notify the healthcare provider? 1. The 1-year-old child with iron deficiency anemia who has dark-colored stool. 2. The 3-year-old child with phenylketonuria (PKU) whose parent does not feed the child any meat or milk products. 3. The 5-year-old child with rheumatic heart fever who is having difficulty breathing. 4. The 7-year-old child diagnosed with acute glomerulonephritis who has dark "tea"-colored urine. Rationale Correct - 3-A complication of rheumatic heart disease is valvular disorders that may be mani- fested by respiratory problems; therefore, the nurse should notify the child's health- care provider. 15. The pediatric nurse on the surgical unit has just received a.m. shift report. Which client should the nurse assess first? 1. The 3-week-old child 1 day postoperative with surgical repair of a myelomeningo- cele who has bulging fontanels. Correct - 1-Bulging fontanels is a sign of increased intracranial pressure, which is a compli- cation of neurological surgery; therefore, this child should be assessed first. 16. The charge nurse has assigned a staff nurse to care for an 8-year-old client diagnosed with cerebral palsy. Which nursing action by the staff nurse would warrant immediate intervention by the charge nurse? 4. The staff nurse places the child in semi-Fowler's position to eat lunch. Rationale Correct - 4-The child should be positioned upright to prevent aspiration during meals; there- fore, this action would require the charge nurse to intervene. 17. The nurse and the unlicensed assistive personnel (UAP) are caring for clients on the pediatric unit. Which action by the nurse indicates appropriate delegation? 4. The nurse checks to make sure the UAP's delegated tasks have been completed. Rationale Correct - 4. The last step of delegating to a UAP is for the nurse to evaluate and determine whether the delegated tasks have been completed and performed correctly. This indicates the nurse has delegated appropriately. 18. The nurse on a pediatric unit has received the a.m. shift report and tells the unli- censed assistive personnel (UAP) to keep the 2-year-old child NPO for a procedure. At 0830, the nurse observes the mother feeding the child. Which action should the nurse implement first? 1. Determine what the UAP did not understand about the instruction. Rationale Correct - 1.Communication to the UAP must be clear, concise, correct, and complete. The nurse must determine why there was a lack of communication, which resulted in the child receiving food; therefore, this action should be implemented first. 19. The charge nurse on the six-bed pediatric burn unit is making shift assignments and has one registered nurse (RN), one scrub technician, one unlicensed assistive personnel (UAP), and a unit secretary. Which client care assignment indicates the best use of the hospital personnel? 1. The RN performs daily whirlpool dressing changes. 2. The unit secretary transcribes the HCP's orders. 3. The scrub technician medicates the client prior to dressing changes. 4. The UAP places the current laboratory results on the chart. 1-The scrub technician is assigned to perform daily whirlpool dressing changes, which is a lengthy procedure. Therefore, assigning the one RN to this task would be inappropriate because he or she cannot be unavailable for an extended period of time. **2-One of the responsibilities of the unit secretary is to transcribe the HCP's orders, but the licensed nurse retains total responsibility for the correctness and accuracy of the transcribed orders. 3-The scrub technician cannot administer medications. 4-The unit secretary and laboratory personnel are responsible for posting laboratory data into the client's charts. The UAP should be on the unit taking care of the clients. 20. The RN and the UAP are caring for clients on a pediatric surgical unit. Which tasks would be most appropriate to delegate to the UAP? Select all that apply. 1. Pass dietary trays to the clients. 2. Obtain routine vital signs on the clients. 3. Complete the preoperative checklist. 4. Change linens on the clients' beds. 5. Document the clients' intake and output. 1, 2, 4, and 5 are correct. 1. The UAP can pass the dietary trays to the clients because it does not require judgment. 2. One of the responsibilities of the UAP is taking routine vital signs on clients. 3. The nurse must complete the preoperative checklist because it requires nursing judg- ment to determine whether the client is ready for surgery. 4. One of the responsibilities of the UAP is changing bed linens. 5. The UAP can document the client's in- take and output, but the UAP cannot evaluate the numbers. 21. Which client should the charge nurse on the pediatric unit assign to the most experienced nurse? 1. The 4-year-old child diagnosed with hemophilia receiving factor VIII. 2. The 8-year-old child with headaches who is scheduled for a CT scan. 3. The 6-year-old child recovering from a sickle cell crisis. 4. The 11-year-old child newly diagnosed with rheumatoid arthritis. 1-The administration of blood products does not require the most experienced nurse. 2-Preparing a child for a routine procedure does not require the most experienced nurse. 3-The child recovering from a sickle cell crisis would not require the most experienced nurse. **4-The child newly diagnosed with a chronic disease, which will have acute exacerba- tions, requires extensive teaching; there- fore, the most experienced nurse should be assigned to this child and family. 22. The charge nurse is making shift assignments on a pediatric oncology unit. Which delegation/assignment would be most appropriate? 1. Delegate the unlicensed assistive personnel (UAP) to obtain routine blood work from the central line. 2. Instruct the licensed practical nurse (LPN) to contact the leukemia support group. 3. Assign the chemotherapy-certified RN to administer chemotherapeutic medication. 4. Have the dietitian check the meal trays for the amount eaten. 1-Only an RN can withdraw blood from a central line. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 51. The nurse is caring for newborns in the nursery. Which newborn warrants immediate intervention by the nurse? 1. The 8-hour-old newborn who has not passed meconium. 2. The 15-hour-old newborn who is slightly jaundiced. 3. The 4-hour-old newborn who is jittery and irritable. 4. The 10-hour-old newborn who will not stop crying. 1.The nurse would not be concerned about not passing meconium until at least 24 hours after delivery. 2. The nurse would not be concerned about a newborn who is slightly jaundiced until after 24 hours after delivery, at which point the HCP would investigate to determine whether the jaundice is pathological. **3. A newborn who is jittery and irritable needs to be assessed first for possible hypoglycemia. The nurse could feed the newborn glucose water or provide more frequent, regular feedings. 4. Although the nurse should determine why the newborn will not stop crying, the new- born who is showing signs of hypoglycemia warrants immediate intervention. 53. The nurse who has never worked on the maternity ward has been pulled from the surgical unit to work in the newborn nursery. Which assignment would be most appropriate for the nurse to accept? 1. Perform an assessment on the newborn. 2. Assist the pediatrician with a circumcision. 3. Gavage feed a newborn who is 8 hours old. 4. Transport newborns to the mothers' room. 1.The nurse should not accept any assign- ment for which he or she is unqualified. A newborn assessment requires specialized knowledge and skills to detect potential complications. 2. The nurse who is not familiar with the pro- cedure or the unit should not be assigned to assist a pediatrician to perform a procedure. 3. This is a dangerous procedure because the nurse must insert a tube into the newborn's stomach. A nurse who is not familiar with this procedure should refuse the assignment. **4. Any nurse can take an infant to the mother's room and check the bands to ensure the right infant is with the right mother. This is an appropriate task for a nurse who has never worked in the nursery. 54. The nurse is instructing the unlicensed assistive personnel (UAP) on gross motor skill activity that is appropriate for a developmentally delayed 9-month-old infant. Which activity should the nurse delegate to the UAP? 1. Help the child to sit without support. 2. Teach the child to catch the beach ball. 3. Reward the child with food for sitting up. 4. Teach the child to blow a kiss. **1. The 9-month-old infant should be able to sit without support. Therefore, the nurse should instruct the UAP to perform the developmental task of helping the child sit without support. 2. Teaching a child to catch a beach ball would be appropriate for a 15- to 18-month-old child, so the nurse should not instruct the UAP to perform this task. 3. The UAP should not use food as a reward or comfort measure because it may lead to childhood obesity. 4. Teaching a child how to blow a kiss is a language/cognitive activity and will not help the child's gross motor development. 55. Which incident should the primary nurse report to the clinical manager concerning a violation of information technology guidelines? 1. The nurse keeps the computer screen turned away from public view. 2. The nurse researches medications using the online formulary. 3. The nurse shares the computer access code with another nurse. 4. The nurse logs off the computer when leaving the terminal. 1. Making sure no one can view the screen is an appropriate information technology guideline. 2. Researching medication online is ensuring safe and effective nursing care and shows that the nurse is keeping abreast of new medications. **3. According to the NCLEX-RN® test blueprint, the nurse must be knowledge- able of information technology. Giving another nurse his or her access code is a very serious violation of information technology guidelines and should be reported. 4. Logging off the computer is an appropriate information technology guideline. 56. The nurse is caring for clients in a pediatric emergency department (ED). Which client should the nurse assess first? 1. The child with a dog bite on the left hand who is bleeding. 2. The child who has a laceration on the right side of the forehead. 3. The child with a fractured tibia who will not move the foot. 4. The child who has ingested a bottle of prenatal vitamins. 1. A dog bite is an emergency, but it is not life threatening; therefore, this child would not be assessed first. 2. The child with a head laceration must be assessed, but not before a child who might die of medication poisoning. 3. The child with a fractured tibia would not be expected to move the foot. **4. A child who ingested a bottle of prenatal vitamins presents a medication poisoning that is a potentially life-threatening situa- tion. This child must be assessed first to determine how many vitamins were taken, how long ago they were taken, and whether or not the vitamins contained iron. The child's neurological status must also be assessed. 57. The nurse is caring for a client in a children's medical center. Which behavior indicates the nurse understands the pediatric client's rights? 1. The nurse administers an injection without talking to the child. 2. The nurse covers the 5-year-old child's genitalia during a code. 3. The nurse discusses the child's condition with the grandparents. 4. The nurse leaves an uncapped needle at the client's bedside. 1. The pediatric client has the right to an explanation of procedures being done to his or her body. **2. The pediatric client has a right to be treated with dignity and respect. Just because the child is being coded does not mean the nurse should allow the child's body to be exposed to everyone in the room. 3. The pediatric client has a right to confiden- tiality, and the parents/legal guardians are the only individuals who have a right to the child's health information. Talking to the grandparents is a violation of HIPAA unless the parents have approved. 4. The nurse is responsible and accountable to protect the health, safety, and rights of the pediatric client. Leaving an uncapped needle at the bedside could cause serious harm to the child. 58. The home health nurse is planning the care of a 14-year-old client diagnosed with leukemia who is receiving chemotherapy. Which psychosocial problem is priority for this client? 1. Diversional activity deficit. 2. High risk for infection. 3. Social isolation. 4. Hopelessness. 1. Diversional activity deficit would be appro- priate if the client did not have sufficient activities to keep him or her occupied. Most children of this age will watch television, play video games, or read books. 2. The client has leukemia and is receiving chemotherapy, which leads to an increased risk of infection; however, this is a physiolog- ical problem, not a psychosocial problem. **3. The client will be isolated from peers and schools because of the high risk of infec- tion resulting from the immunosuppres- sion secondary to chemotherapy and the disease process. At this stage, the child needs to be developing peer relationships and independence from parents. There- fore, social isolation is the priority psy- chosocial problem for this client. 4. The nurse should not identify hopelessness because childhood leukemia has a good prognosis. 59. The nurse is administering IV fluids to a 3-year-old client. Which action by the nurse would warrant intervention by the charge nurse? 1. The nurse places the IV on an infusion pump. 2. The nurse does not use a volume-controlled chamber. 3. The nurse checks the child's IV site every hour. 4. The nurse labels the IV tubing with date and time. 1.Placing the IV line on an infusion pump helps to make sure the client does not receive an overload of IV fluid. Most facilities require an IV pump and volume-controlled chamber when administering fluids in a pediatric clinic. **2.A volume-controlled chamber (Buretrol) is a device that is used with children when administering IV fluids. The cham- ber is filled with 1 hour's amount of fluid so that the child will not inadvertently re- ceive an overload of fluid. Fluid volume overload is a potentially life-threatening situation in children. 3. The site should be checked frequently to en- sure that the IV does not infiltrate; therefore, this does not warrant intervention. 4. The IV tubing should not be used longer than 72 hours; therefore, labeling the tubing with the date and time would not warrant intervention. 60. The nurse is caring for clients on a psychiatric pediatric unit. Which action by the nurse is reportable to the state board of nursing? 1. The nurse leaves for lunch and does not return to complete the shift. 2. The nurse fails to check the ID band when administering medications. 3. The nurse has had three documented medication errors in the last 3 months. 4. The nurse has admitted to having an affair with another staff member. **1. Abandonment is a reportable offense to the state board of nursing in every state. Reportable offenses could result in stipulations made to the nurse's license. 2. This is failure to follow the five rights of medication administration, but it is not a reportable offense. 3. Multiple medication errors are a manage- ment issue, not a reportable offense. 4.Having an affair with a fellow employee is not a reportable offense. 61. The nurse is working in a free healthcare clinic. Which client situation warrants further investigation? 1. The child diagnosed with rheumatoid arthritis who is wearing a copper bracelet. 2. The mother of a child with a sunburn who is using juice from an aloe vera plant on the burn. 3. The grandmother who reports rubbing Vick's Vapo-Rub on the child's chest for a cold. 4. The father who tells the nurse that the child receives a variety of herbs every day. 1. A copper bracelet may or may not help the child with rheumatoid arthritis, but because it will not hurt the child, it does not warrant further investigation. 2. Aloe vera is used in many topical burn prepa- rations; therefore, this practice would not warrant further investigation. 3. Vick's VapoRub may or may not help the child's cold, but, because it will not hurt the child, it does not warrant further investigation. **4. Herbal products are not regulated by the Food and Drug Administration, and there is very little (if any) research on herbal use with children. The nurse should at least investigate which herbs the child is receiving before taking further action. 62. The unlicensed assistive personnel (UAP) tells the primary nurse that the 4-year-old child is alone in the room because the mother went to the cafeteria to get something to eat. Which action should the nurse implement first? 1. Arrange for the mother to have a tray sent to the room. 2. Go to the cafeteria and ask the mother to return to the room. 3. Tell the UAP to stay with the child until the mother returns. 4. Notify social services that the mother left the child alone. 1.This is an appropriate nursing intervention so that the mother will not have to leave her child, but it is not the first intervention. The child's safety is priority. 2. The nurse could go to the cafeteria and tell the mother to return to the room, but during this time the UAP should stay with the child. **3. The child's safety is priority; therefore, the nurse should have the UAP stay with the child until the mother returns. 4. Social services would not need to be notified at this time. If the mother continually leaves the child alone, then this would be an appropriate action. 63. The nurse is evaluating an 18-month-old child in the pediatric clinic. Which data would indicate to the nurse that the child is not meeting tasks according to Erikson's Stages of Psychosocial Development? 1. The child stamps his or her foot and says "no" frequently. 2. The child does not interact with the mother. 3. The child cries when the mother leaves the room. 4. The child responds when called by name. 1.An 18-month-old child should be throwing temper tantrums. This indicates the child is developing a sense of autonomy. **2.An 18-month-old child should cling to the mother and interact continuously with the primary caregiver. A child not interacting with the mother is not meeting the task of developing a sense of autonomy. 3.The child has met the task of trust when he or she cries if the mother leaves the room. 4.When a child responds to his or her name, it indicates a sense of identity; therefore, the task is met. 64. Which statement by the female charge nurse indicates she has an autocratic leadership style? 1. "You must complete all the a.m. care before you take your morning break." 2. "I don't care how the work is done as long as it is completed on time." 3. "I would like to talk to you about your ideas on a new staffing mix." 4. "I think we should have a pot luck lunch tomorrow because it is Saturday." **1. An autocratic manager uses an authori- tarian approach to direct the activities of others. This individual makes most of the decisions alone without input from other staff members. 2. A laissez-faire manager maintains a permis- sive climate with little direction or control. 3. A democratic manager is people oriented and emphasizes efficient group functioning. The environment is open, and communication flows both ways. 4. A democratic manager is people oriented and emphasizes efficient group functioning. 65. The nurse is evaluating the care of a 5-year-old client with a cyanotic congenital heart defect. Which client outcome would support that discharge teaching has been effective? 1. The mother makes the child get up when squatting. 2. The child is playing in the dayroom without oxygen. 3. The father buys the child a baseball and a bat. 4. The nurse finds unopened packs of salt on the meal tray. 1. Squatting relieves the hypoxic episodes, and the child should be able to remain in the squatting position. 2. The child with a cyanotic, congenital heart defect should have oxygen when being active. 3. This indicates the father does not understand that the child will not be able to participate in active sports because of the stress that is placed on the heart. **4. This behavior indicates the child under- stands the importance of salt restriction because of potential congestive heart failure. 69. The unconscious 4-year-old child is brought to the emergency department by para- medics; the child has bruises covering the torso in varying stages of healing. The nurse notes small burn marks on the child's genitalia. Which actions should the nurse implement? Select all that apply. 1. Notify Child Protective Services. 2. Ask the parent how the child was injured. 3. Perform a thorough examination for more injuries. 4. Tell the parents that the police have been called. 5. Prepare the child for skull x-rays and a CT scan. 1, 3, and 5 are correct. 1. This child has injuries consistent with child abuse. Child Protective Services and the police should be notified. 2. This could result in not being able to prose- cute the perpetrator if the nurse is not trained in forensic medicine. 3. The nurse should determine the full extent of the child's injuries. 4. The nurse should not notify the parent of the potential involvement. The police are fully capable of doing this for themselves. The nurse could instigate an inflammatory situation with this action. 5. The child needs x-ray studies to deter- mine the extent of internal injuries. 70. The 24-month-old toddler is admitted to the pediatric unit with vomiting and diarrhea. Which interventions should the nurse implement? Rank in order of performance. 1. Teach the parent about weighing diapers to determine output status. 2. Show the parent the call light and explain safety regimens. 3. Assess the toddler's tissue turgor. 4. Place the appropriate size diapers in the room. 5. Take the toddler's vital signs. Rationale Correct Answer: 5, 3, 2, 4, 1 5. Taking the vital signs is part of the assess- ment and a beginning point for the nurse. 3. Since the child has been losing fluids, the nurse should assess tissue turgor to try and determine whether fluid replacement by the parents has been effective. 2. The nurse should make sure that the parents do not leave the child alone in the room and make sure the parents are aware of any safety measures used to protect the toddler from abduction and how to call the nurse in case of need. 4. The parents will need to change diapers so the child will not develop skin irrita- tion problems. 1. When the nurse provides diapers it is a good opportunity to teach the parents about weighing the diapers before and after the child soils them. During a mental status assessment, which question by the nurse would best assess a person's judgment?