HESI A2 CRITICAL THINKING
1. A client who is in hospice care complains of increasing amounts of pain. The healthcare
provider prescribes an analgesic every four hours as needed. Which action should the
nurse implement?
Give an around-the-clock schedule for administration of analgesics.
2. The nurse is administering medications through a nasogastric tube (NGT) which is
connected to suction. After ensuring correct tube placement, what action should the nurse
take next?
Flush the tube with water.
3. An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is
essential to the client's nursing care?
Gently lift the client when moving into a desired position.
4. When assessing a client with wrist restraints, the nurse observes that the fingers on the
right hand are blue. What action should the nurse implement first?
Loosen the right wrist restraint.
5. The nurse is assessing the nutritional status of several clients. Which client has the
greatest nutritional need for additional intake of protein?
A lactating woman nursing her 3-day-old infant.
, 6. A client is in the radiology department at 0900 when the prescription levofloxacin
(Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit
at 1300. What is the best intervention for the nurse to implement?
Give the missed dose at 1300 and change the schedule to administer daily at 1300.
7. While instructing a male client's wife in the performance of passive range-of-motion
exercises to his contracted shoulder, the nurse observes that she is holding his arm above
and below the elbow. What nursing action should the nurse implement?
Acknowledge that she is supporting the arm correctly.
8. What is the most important reason for starting intravenous infusions in the upper
extremities rather than the lower extremities of adults?
A decreased flow rate could result in the formation of a thrombosis.
9. The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood
pressure with a cuff that is too small, but the blood pressure reading obtained is within
the client's usual range. What action is most important for the nurse to implement?
Reassess the client's blood pressure using a larger cuff.
10. Twenty minutes after beginning a heat application, the client states that the heating pad
no longer feels warm enough. What is the best response by the nurse?
The body's receptors adapt over time as they are exposed to heat.
1. A client who is in hospice care complains of increasing amounts of pain. The healthcare
provider prescribes an analgesic every four hours as needed. Which action should the
nurse implement?
Give an around-the-clock schedule for administration of analgesics.
2. The nurse is administering medications through a nasogastric tube (NGT) which is
connected to suction. After ensuring correct tube placement, what action should the nurse
take next?
Flush the tube with water.
3. An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is
essential to the client's nursing care?
Gently lift the client when moving into a desired position.
4. When assessing a client with wrist restraints, the nurse observes that the fingers on the
right hand are blue. What action should the nurse implement first?
Loosen the right wrist restraint.
5. The nurse is assessing the nutritional status of several clients. Which client has the
greatest nutritional need for additional intake of protein?
A lactating woman nursing her 3-day-old infant.
, 6. A client is in the radiology department at 0900 when the prescription levofloxacin
(Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit
at 1300. What is the best intervention for the nurse to implement?
Give the missed dose at 1300 and change the schedule to administer daily at 1300.
7. While instructing a male client's wife in the performance of passive range-of-motion
exercises to his contracted shoulder, the nurse observes that she is holding his arm above
and below the elbow. What nursing action should the nurse implement?
Acknowledge that she is supporting the arm correctly.
8. What is the most important reason for starting intravenous infusions in the upper
extremities rather than the lower extremities of adults?
A decreased flow rate could result in the formation of a thrombosis.
9. The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood
pressure with a cuff that is too small, but the blood pressure reading obtained is within
the client's usual range. What action is most important for the nurse to implement?
Reassess the client's blood pressure using a larger cuff.
10. Twenty minutes after beginning a heat application, the client states that the heating pad
no longer feels warm enough. What is the best response by the nurse?
The body's receptors adapt over time as they are exposed to heat.
