HESI A2 Nursing Critical Thinking Questions & Answers: Updated A+ Score Guide

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? A. Prescribe me ...

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? A. Prescribe medicine to induce vomiting. B. Determine the patient's level of consciousness. C. Ask the family why he may have taken an entire bottle of pills. (Ans- B. 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 liters 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? A. Assess the patient's oxygen saturation by a pulse oximeter. B. Ask the patient to lie down and wait to see if it happens again. C. Begin administering 2.5 liters of oxygen per minute. (Ans- A. Assess the patient's oxygen saturation by a 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? A. Prescribe an anti-vomiting medication B. Administer a prescribed pain medication C. Check for dehydration from vomiting. (Ans- B. 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? A. Advise the patient to have her husband take the items home when he leaves. B. Offer to put the items in a safe downstairs. C. Offer to put the items in the nurses' station. (Ans- A. 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? A. Ask when the patient smoked her last cigarette. B. When did her leg hurt last, C. A previous blood clot in the leg (Ans- C. 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? A. Give the patient more fever-reducing medication. B. Sponge the patient with cool water. C. Wait thirty more minutes for the medicine to kick in. (Ans- B. 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? A. Determine if the patient is allergic to the medication B. Ask if the patient has taken any similar medications to that one. C. Determine the exact dosage needed. (Ans- A. 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? A. Assume she is confused and continue to offer the medication. B. Withhold the medication until the patient's prescription is verified. C. Discard the medication. (Ans- B. Withhold the medication until the patient's prescription is verified.