HESI A2 Critical Thinking Q&A

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.