HESI A2 Critical Thinking Q&A
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. 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:
