HESI A2 Nursing Critical Thinking

HESI A2 Nursing Critical Thinking

• 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?

• Prescribe medicine to induce vomiting.
• Determine the patient's level of consciousness.
• 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?

• Assess the patient's oxygen saturation by a pulse oximeter.
• Ask the patient to lie down and wait to see if it happens again.
• Begin administering 2.5 liters of oxygen per minute.

(Ans- A. Assess the patient's oxygen saturation by a pulse oximeter.

• 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?

• Prescribe an anti-vomiting medication
• Administer a prescribed pain medication 1 / 2

• 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?

• Advise the patient to have her husband take the items home when he

leaves.

• Offer to put the items in a safe downstairs.
• 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?

• Ask when the patient smoked her last cigarette.
• When did her leg hurt last,
• A previous blood clot in the leg

(Ans- C. A previous blood clot in the leg

• 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

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