HESI A2 - Critical Thinking with
correct answers 2025
1.vThevnursevisvworkingvinvthevemergencyvdepartmentv(ED)vofvavchildren'svmedicalvcenter.vWhichvcl
ientvshouldvthevnursevassessvfirst?
1.vThev1-month-oldvinfantvwhovhasvdevelopedvcolicvandvisvcrying.
2.vThev2-year-oldvtoddlervwhovwasvbittenvbyvanothervchildvatvthevday-carevcenter.v3.vThev6-year-
oldvschool-agevchildvwhovwasvhitvbyvavcarvwhilevridingvavbicycle.
4.vThev14-year-oldvadolescentvwhosevmothervsuspectsvhervchildvisvsexuallyvactive.v-vcorrect-
answersv-Rationalev
Correctv-v3-Thevchildvhitvbyvavcarvshouldvbevassessedvfirstvbecausevhevorvshevmayvhavevlife-
vthreateningvinjuriesvthatvmustvbevassessedvandvtreatedvpromptly.
1.vInvanvinterview,vthevnursevmayvfindvitvnecessaryvtovtakevnotesvtovaidvhisvorvhervmemoryvlater.vWh
ichvstatementvisvtruevregardingvnote-taking?v
A)vNote-takingvmayvimpedevthevnurse'svobservationvofvthevpatient'svnonverbalvbehaviors.
B)vNote-
takingvallowsvthevpatientvtovcontinuevatvhisvorvhervownvpacevasvthevnursevrecordsvwhatvisvsaid.
,C)vNote-
takingvallowsvthevnursevtovshiftvattentionvawayvfromvthevpatient,vresultingvinvanvincreasedvcomfortv
level.
D)vNote-
takingvallowsvthevnursevtovbreakveyevcontactvwithvthevpatient,vwhichvmayvincreasevhisvorvhervlevelv
ofvcomfort.v-vcorrect-answersv-A)vNote-
takingvmayvimpedevthevnurse'svobservationvofvthevpatient'svnonverbalvbehaviors.
Page:v31vSomevusevofvhistoryvformsvandvnote-takingvmayvbevunavoidable.vButvbevawarevthatvnote-
takingvduringvthevinterviewvhasvdisadvantages.vItvbreaksveyevcontactvtoovoften,vandvitvshiftsvattenti
onvawayvfromvthevpatient,vwhichvdiminishesvhisvorvhervsensevofvimportance.vItvalsovmayvinterruptvt
hevpatient'svnarrativevflow,vandvitvimpedesvthevobservationvofvthevpatient'svnonverbalvbehavior.
2.vThev8-year-oldvclientvdiagnosedvwithvavvaso-
occlusivevsicklevcellvcrisisvisvcomplainingvofvavseverevheadache.vWhichvinterventionvshouldvthevnur
sevimplementvfirst?
1.vAdministerv6vLvofvoxygenvviavnasalvcannula.
2.vAssessvthevclient'svneurologicalvstatus.
3.vAdministervavnarcoticvanalgesicvbyvintravenousvpushv(IVP).v4.vIncreasevthevclient'svintravenousv(I
V)vrate.v-vcorrect-answersv-Rationalev
Correctv-v2-
Becausevthevclientvisvcomplainingvofvavheadache,vthevnursevshouldvfirstvrulevoutvcerebrovascularva
ccidentv(CVA)vbyvassess-
vingvthevclient'svneurologicalvstatusvandvthenvdeterminevwhethervitvisvavheadachevthatvcanvbevtreat
edvwithvmedication.
2.vDuringvanvinterview,vthevnursevstates,v"Youvmentionedvshortnessvofvbreath.vTellvmevmorevaboutv
that."vWhichvverbalvskillvisvusedvwithvthisvstatement?
A)vReflection
B)vFacilitation
,C)vDirectvquestion
D)vOpen-endedvquestionv-vcorrect-answersv-D)vOpen-endedvquestion
Page:v32vThevopen-
endedvquestionvasksvforvnarrativevinformation.vItvstatesvthevtopicvtovbevdiscussedvbutvonlyvinvgene
ralvterms.vThevnursevshouldvusevitvtovbeginvthevinterview,vtovintroducevavnewvsectionvofvquestions,v
andvwhenevervthevpersonvintroducesvavnewvtopic.
3.vThev6-year-
oldvclientvwhovhasvundergonevabdominalvsurgeryvisvattemptingvtovmakevavpinwheelvspinvbyvblowi
ngvonvitvwithvthevnurse'svassistance.vThevchildvstartsvcryingvbecausevthevpinwheelvwon'tvspin.vWhic
hvactionvshouldvthevnursevimplementvfirst?
1.vPraisevthevchildvforvthevattemptvtovmakevthevpinwheelvspin.
2.vNotifyvthevrespiratoryvtherapistvtovimplementvincentivevspirometry.v3.vEncouragevthevchildvtovtu
rnvfromvsidevtovsidevandvcough.
4.vDemonstratevhowvtovmakevthevpinwheelvspinvbyvblowingvonvit.v-vcorrect-answersv-Rationalev
Correctv-
1.vThevnursevshouldvalwaysvpraisevthevchildvforvattemptsvatvcooperationvevenvifvthevchildvdidvnotvac
complishvwhatvthevnursevasked.
3.vAvnursevisvtakingvcompletevhealthvhistoriesvonvallvofvthevpatientsvattendingvavwellnessvworkshop
.vOnvthevhistoryvform,vonevofvthevwrittenvquestionsvasks,v"Youvdon'tvsmoke,vdrink,vorvtakevdrugs,vd
ovyou?"vThisvquestionvisvanvexamplevof:
A)vtalkingvtoovmuch.
B)vusingvconfrontation.
C)vusingvbiasedvorvleadingvquestions.
D)vusingvbluntvlanguagevtovdealvwithvdistastefulvtopics.v-vcorrect-answersv-
C)vusingvbiasedvorvleadingvquestions.
, Page:v36vThisvisvanvexamplevofvusingvleadingvorvbiasedvquestions.vAsking,v"Youvdon'tvsmoke,vdovyo
u?"vimpliesvthatvonevanswervisv"better"vthanvanother.vIfvthevpersonvwantsvtovpleasevsomeone,vhevo
rvshevisveithervforcedvtovanswervinvavwayvcorrespondingvtovtheirvimpliedvvaluesvorvisvmadevtovfeelvg
uiltyvwhenvadmittingvthevothervanswer.
4.vThevnursevisvcaringvforvclientsvonvthevpediatricvmedicalvunit.vWhichvclientvshouldvthevnursevasses
svfirst?
1.vThevchildvdiagnosedvwithvtypev1vdiabetesvwhovhasvavbloodvglucosevlevel
ofv180vmg/dL.
2.vThevchildvdiagnosedvwithvpneumoniavwhovisvcoughingvandvhasvavtemperaturevof
100°F.
3.vThevchildvdiagnosedvwithvgastroenteritisvwhovhasvavpotassiumv(K+)vlevel
ofv3.9vmEq/L.
4.vThevchildvdiagnosedvwithvcysticvfibrosisvwhovhasvavpulsevoximetervreadingvofv90%.v-vcorrect-
answersv-Rationalev
Correctv-
v4.vAvpulsevoximetervreadingvofvlessvthanv93%visvsignificantvandvindicatesvhypoxia,vwhichvisvlifevthre
atening;vtherefore,vthisvchildvshouldvbevassessedvfirst.
4.vDuringvanvinterview,vavparentvofvavhospitalizedvchildvisvsittingvinvanvopenvposition.vAsvthevintervi
ewervbeginsvtovdiscussvhisvson'svtreatment,vhowever,vhevsuddenlyvcrossesvhisvarmsvagainstvhisvche
stvandvcrossesvhisvlegs.vThisvwouldvsuggestvthatvthevparentvis:
A)vjustvchangingvpositions.
B)vmorevcomfortablevinvthisvposition.
C)vtiredvandvneedsvavbreakvfromvthevinterview.
correct answers 2025
1.vThevnursevisvworkingvinvthevemergencyvdepartmentv(ED)vofvavchildren'svmedicalvcenter.vWhichvcl
ientvshouldvthevnursevassessvfirst?
1.vThev1-month-oldvinfantvwhovhasvdevelopedvcolicvandvisvcrying.
2.vThev2-year-oldvtoddlervwhovwasvbittenvbyvanothervchildvatvthevday-carevcenter.v3.vThev6-year-
oldvschool-agevchildvwhovwasvhitvbyvavcarvwhilevridingvavbicycle.
4.vThev14-year-oldvadolescentvwhosevmothervsuspectsvhervchildvisvsexuallyvactive.v-vcorrect-
answersv-Rationalev
Correctv-v3-Thevchildvhitvbyvavcarvshouldvbevassessedvfirstvbecausevhevorvshevmayvhavevlife-
vthreateningvinjuriesvthatvmustvbevassessedvandvtreatedvpromptly.
1.vInvanvinterview,vthevnursevmayvfindvitvnecessaryvtovtakevnotesvtovaidvhisvorvhervmemoryvlater.vWh
ichvstatementvisvtruevregardingvnote-taking?v
A)vNote-takingvmayvimpedevthevnurse'svobservationvofvthevpatient'svnonverbalvbehaviors.
B)vNote-
takingvallowsvthevpatientvtovcontinuevatvhisvorvhervownvpacevasvthevnursevrecordsvwhatvisvsaid.
,C)vNote-
takingvallowsvthevnursevtovshiftvattentionvawayvfromvthevpatient,vresultingvinvanvincreasedvcomfortv
level.
D)vNote-
takingvallowsvthevnursevtovbreakveyevcontactvwithvthevpatient,vwhichvmayvincreasevhisvorvhervlevelv
ofvcomfort.v-vcorrect-answersv-A)vNote-
takingvmayvimpedevthevnurse'svobservationvofvthevpatient'svnonverbalvbehaviors.
Page:v31vSomevusevofvhistoryvformsvandvnote-takingvmayvbevunavoidable.vButvbevawarevthatvnote-
takingvduringvthevinterviewvhasvdisadvantages.vItvbreaksveyevcontactvtoovoften,vandvitvshiftsvattenti
onvawayvfromvthevpatient,vwhichvdiminishesvhisvorvhervsensevofvimportance.vItvalsovmayvinterruptvt
hevpatient'svnarrativevflow,vandvitvimpedesvthevobservationvofvthevpatient'svnonverbalvbehavior.
2.vThev8-year-oldvclientvdiagnosedvwithvavvaso-
occlusivevsicklevcellvcrisisvisvcomplainingvofvavseverevheadache.vWhichvinterventionvshouldvthevnur
sevimplementvfirst?
1.vAdministerv6vLvofvoxygenvviavnasalvcannula.
2.vAssessvthevclient'svneurologicalvstatus.
3.vAdministervavnarcoticvanalgesicvbyvintravenousvpushv(IVP).v4.vIncreasevthevclient'svintravenousv(I
V)vrate.v-vcorrect-answersv-Rationalev
Correctv-v2-
Becausevthevclientvisvcomplainingvofvavheadache,vthevnursevshouldvfirstvrulevoutvcerebrovascularva
ccidentv(CVA)vbyvassess-
vingvthevclient'svneurologicalvstatusvandvthenvdeterminevwhethervitvisvavheadachevthatvcanvbevtreat
edvwithvmedication.
2.vDuringvanvinterview,vthevnursevstates,v"Youvmentionedvshortnessvofvbreath.vTellvmevmorevaboutv
that."vWhichvverbalvskillvisvusedvwithvthisvstatement?
A)vReflection
B)vFacilitation
,C)vDirectvquestion
D)vOpen-endedvquestionv-vcorrect-answersv-D)vOpen-endedvquestion
Page:v32vThevopen-
endedvquestionvasksvforvnarrativevinformation.vItvstatesvthevtopicvtovbevdiscussedvbutvonlyvinvgene
ralvterms.vThevnursevshouldvusevitvtovbeginvthevinterview,vtovintroducevavnewvsectionvofvquestions,v
andvwhenevervthevpersonvintroducesvavnewvtopic.
3.vThev6-year-
oldvclientvwhovhasvundergonevabdominalvsurgeryvisvattemptingvtovmakevavpinwheelvspinvbyvblowi
ngvonvitvwithvthevnurse'svassistance.vThevchildvstartsvcryingvbecausevthevpinwheelvwon'tvspin.vWhic
hvactionvshouldvthevnursevimplementvfirst?
1.vPraisevthevchildvforvthevattemptvtovmakevthevpinwheelvspin.
2.vNotifyvthevrespiratoryvtherapistvtovimplementvincentivevspirometry.v3.vEncouragevthevchildvtovtu
rnvfromvsidevtovsidevandvcough.
4.vDemonstratevhowvtovmakevthevpinwheelvspinvbyvblowingvonvit.v-vcorrect-answersv-Rationalev
Correctv-
1.vThevnursevshouldvalwaysvpraisevthevchildvforvattemptsvatvcooperationvevenvifvthevchildvdidvnotvac
complishvwhatvthevnursevasked.
3.vAvnursevisvtakingvcompletevhealthvhistoriesvonvallvofvthevpatientsvattendingvavwellnessvworkshop
.vOnvthevhistoryvform,vonevofvthevwrittenvquestionsvasks,v"Youvdon'tvsmoke,vdrink,vorvtakevdrugs,vd
ovyou?"vThisvquestionvisvanvexamplevof:
A)vtalkingvtoovmuch.
B)vusingvconfrontation.
C)vusingvbiasedvorvleadingvquestions.
D)vusingvbluntvlanguagevtovdealvwithvdistastefulvtopics.v-vcorrect-answersv-
C)vusingvbiasedvorvleadingvquestions.
, Page:v36vThisvisvanvexamplevofvusingvleadingvorvbiasedvquestions.vAsking,v"Youvdon'tvsmoke,vdovyo
u?"vimpliesvthatvonevanswervisv"better"vthanvanother.vIfvthevpersonvwantsvtovpleasevsomeone,vhevo
rvshevisveithervforcedvtovanswervinvavwayvcorrespondingvtovtheirvimpliedvvaluesvorvisvmadevtovfeelvg
uiltyvwhenvadmittingvthevothervanswer.
4.vThevnursevisvcaringvforvclientsvonvthevpediatricvmedicalvunit.vWhichvclientvshouldvthevnursevasses
svfirst?
1.vThevchildvdiagnosedvwithvtypev1vdiabetesvwhovhasvavbloodvglucosevlevel
ofv180vmg/dL.
2.vThevchildvdiagnosedvwithvpneumoniavwhovisvcoughingvandvhasvavtemperaturevof
100°F.
3.vThevchildvdiagnosedvwithvgastroenteritisvwhovhasvavpotassiumv(K+)vlevel
ofv3.9vmEq/L.
4.vThevchildvdiagnosedvwithvcysticvfibrosisvwhovhasvavpulsevoximetervreadingvofv90%.v-vcorrect-
answersv-Rationalev
Correctv-
v4.vAvpulsevoximetervreadingvofvlessvthanv93%visvsignificantvandvindicatesvhypoxia,vwhichvisvlifevthre
atening;vtherefore,vthisvchildvshouldvbevassessedvfirst.
4.vDuringvanvinterview,vavparentvofvavhospitalizedvchildvisvsittingvinvanvopenvposition.vAsvthevintervi
ewervbeginsvtovdiscussvhisvson'svtreatment,vhowever,vhevsuddenlyvcrossesvhisvarmsvagainstvhisvche
stvandvcrossesvhisvlegs.vThisvwouldvsuggestvthatvthevparentvis:
A)vjustvchangingvpositions.
B)vmorevcomfortablevinvthisvposition.
C)vtiredvandvneedsvavbreakvfromvthevinterview.
