HESI A2 - Critical Thinking- questions and answers
with Rationale 2025\2026
1. The nurse is working in the emergency department (ED) of a children's medical center. Which client should
the nurse assess first?
1. The 1-month-old infant who has developed colic and is crying.
2. The 2-year-old toddler who was bitten by another child at the day-care center. 3. The 6-year-old school-age
child who was hit by a car while riding a bicycle.
4. The 14-year-old adolescent whose mother suspects her child is sexually active.
Rationale
ANSWERS 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?
1. Administer 6 L of oxygen via nasal cannula.
2. Assess the client's neurological status.
3. Administer a narcotic analgesic by intravenous push (IVP). 4. Increase the client's intravenous (IV) rate.
Rationale
ANSWERS 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?
1. Praise the child for the attempt to make the pinwheel spin.
2. Notify the respiratory therapist to implement incentive spirometry. 3. Encourage the child to turn from side to
side and cough.
4. Demonstrate how to make the pinwheel spin by blowing on it. Rationale
ANSWERS1. 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?
1. The child diagnosed with type 1 diabetes who has a blood glucose levelof 180 mg/dL.
2. The child diagnosed with pneumonia who is coughing and has a temperature of100°F.
3. The child diagnosed with gastroenteritis who has a potassium (K+) levelof 3.9 mEq/L.
4. The child diagnosed with cystic fibrosis who has a pulse oximeter reading of 90%.
Rationale
ANSWERS 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?
1. The third dose of the aminoglycoside antibiotic to the child diagnosed withmethicillin-
resistant Staphylococcus aureus (MRSA).
2. The IVP steroid methylprednisolone (Solu-Medrol) to the child diagnosed withasthma.
1
,3. The sliding scale insulin to the child diagnosed with type 1 diabetes mellitus.4. The
stimulant methylphenidate (Ritalin) to a child diagnosed with attention deficit-hyperactivity
disorder (ADHD). Rationale
ANSWERS 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. 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).
1. Perform cardiac compression 30:2.
2. Check the infant's brachial pulse. 3. Administer two puffs to the infant. 4. Determine unresponsiveness.
5. Open the infant's airway.
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?
1. Orient the parents and child to the room.
2. Obtain an admission kit for the child.
3. Post the child's height and weight at the HOB. 4. Provide the child with a meal tray.
Rationale
ANSWERS 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?
1. Immobilize the child's leg.
2. Explain the procedure to the child.
3. Cleanse the area with an alcohol swab. 4. Administer the medication in the thigh.
Rationale
ANSWERS 2-The nurse must explain any procedure in words the child can understand. It does not matter how old
the child is.
9. The nurse is writing a care plan for the 5-year-old child diagnosed with gastroenteritis. Which client problem is
priority?
1. Imbalanced nutrition.
2. Fluid volume deficit.
3. Knowledge deficit. 4. Risk for infection.
Rationale
ANSWERS 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.
2
, 10. Which data would warrant immediate intervention from the pediatric nurse? 1. Proteinuria for the child
diagnosed with nephrotic syndrome.
2. Petechiae for the child diagnosed with leukemia.
3. Drooling for a child diagnosed with acute epiglottitis.
4. Elevated temperature in a child diagnosed with otitis media.
Rationale
ANSWERS 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? 1. The 6month
old child diagnosed with bacterial meningitis who is irritable and crying.
2. The 9-month old child diagnosed with tetralogy of Fallot (TOF) who has edema ofthe
face.
3. The 11-month old child diagnosed with Reye syndrome who is lethargic andvomiting.
4. The 13-month-old child diagnosed with diarrhea who has sunken eyeballs
anddecreased urine output. Rationale
ANSWERS 4. Sunken eyeballs and decreased urine out- put are signs of dehydration, which is a lifethreatening
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.
2. The 8-month-old whose parent is reporting the child is pulling on the right ear and has a fever.
3. The 2-year-old child who has patent ductus arteriosis whose parent reports running out of digoxin.
4. The 3-year-old child whose mother called and reported her daughter may have chickenpox.
Rationale
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?
1. Prepare to bifurcate the left below-the-knee cast.
2. Tell the parent to bring the child to the office.
3. Instruct the parent to elevate the left leg on two pillows.
4. Notify the child's orthopedist of the situation.
Rationale
ANSWERS 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 thechild 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
ANSWERS 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?
3
with Rationale 2025\2026
1. The nurse is working in the emergency department (ED) of a children's medical center. Which client should
the nurse assess first?
1. The 1-month-old infant who has developed colic and is crying.
2. The 2-year-old toddler who was bitten by another child at the day-care center. 3. The 6-year-old school-age
child who was hit by a car while riding a bicycle.
4. The 14-year-old adolescent whose mother suspects her child is sexually active.
Rationale
ANSWERS 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?
1. Administer 6 L of oxygen via nasal cannula.
2. Assess the client's neurological status.
3. Administer a narcotic analgesic by intravenous push (IVP). 4. Increase the client's intravenous (IV) rate.
Rationale
ANSWERS 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?
1. Praise the child for the attempt to make the pinwheel spin.
2. Notify the respiratory therapist to implement incentive spirometry. 3. Encourage the child to turn from side to
side and cough.
4. Demonstrate how to make the pinwheel spin by blowing on it. Rationale
ANSWERS1. 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?
1. The child diagnosed with type 1 diabetes who has a blood glucose levelof 180 mg/dL.
2. The child diagnosed with pneumonia who is coughing and has a temperature of100°F.
3. The child diagnosed with gastroenteritis who has a potassium (K+) levelof 3.9 mEq/L.
4. The child diagnosed with cystic fibrosis who has a pulse oximeter reading of 90%.
Rationale
ANSWERS 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?
1. The third dose of the aminoglycoside antibiotic to the child diagnosed withmethicillin-
resistant Staphylococcus aureus (MRSA).
2. The IVP steroid methylprednisolone (Solu-Medrol) to the child diagnosed withasthma.
1
,3. The sliding scale insulin to the child diagnosed with type 1 diabetes mellitus.4. The
stimulant methylphenidate (Ritalin) to a child diagnosed with attention deficit-hyperactivity
disorder (ADHD). Rationale
ANSWERS 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. 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).
1. Perform cardiac compression 30:2.
2. Check the infant's brachial pulse. 3. Administer two puffs to the infant. 4. Determine unresponsiveness.
5. Open the infant's airway.
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?
1. Orient the parents and child to the room.
2. Obtain an admission kit for the child.
3. Post the child's height and weight at the HOB. 4. Provide the child with a meal tray.
Rationale
ANSWERS 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?
1. Immobilize the child's leg.
2. Explain the procedure to the child.
3. Cleanse the area with an alcohol swab. 4. Administer the medication in the thigh.
Rationale
ANSWERS 2-The nurse must explain any procedure in words the child can understand. It does not matter how old
the child is.
9. The nurse is writing a care plan for the 5-year-old child diagnosed with gastroenteritis. Which client problem is
priority?
1. Imbalanced nutrition.
2. Fluid volume deficit.
3. Knowledge deficit. 4. Risk for infection.
Rationale
ANSWERS 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.
2
, 10. Which data would warrant immediate intervention from the pediatric nurse? 1. Proteinuria for the child
diagnosed with nephrotic syndrome.
2. Petechiae for the child diagnosed with leukemia.
3. Drooling for a child diagnosed with acute epiglottitis.
4. Elevated temperature in a child diagnosed with otitis media.
Rationale
ANSWERS 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? 1. The 6month
old child diagnosed with bacterial meningitis who is irritable and crying.
2. The 9-month old child diagnosed with tetralogy of Fallot (TOF) who has edema ofthe
face.
3. The 11-month old child diagnosed with Reye syndrome who is lethargic andvomiting.
4. The 13-month-old child diagnosed with diarrhea who has sunken eyeballs
anddecreased urine output. Rationale
ANSWERS 4. Sunken eyeballs and decreased urine out- put are signs of dehydration, which is a lifethreatening
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.
2. The 8-month-old whose parent is reporting the child is pulling on the right ear and has a fever.
3. The 2-year-old child who has patent ductus arteriosis whose parent reports running out of digoxin.
4. The 3-year-old child whose mother called and reported her daughter may have chickenpox.
Rationale
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?
1. Prepare to bifurcate the left below-the-knee cast.
2. Tell the parent to bring the child to the office.
3. Instruct the parent to elevate the left leg on two pillows.
4. Notify the child's orthopedist of the situation.
Rationale
ANSWERS 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 thechild 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
ANSWERS 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?
3
