HESI A2 ENTRANCE EXAM
FOR
CHAMBERLAIN COLLGE OF
NURSING
2023 QUESTIONS WITH
ANSWERS
CRITICAL THINKING
1. The Patient: A 65-year-
... [Show More] 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.
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?
Answer – 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?
Answer – Withhold the mediation until the patient’s prescription is verify.
9. The Patients:
1. A 63-year-old with a burn on the left lower leg who is complaining of pain.
2. A 45-year-old with pneumonia, complaining of shortness of breath.
3. A 31-year-old with abdominal pain who has just vomited blood.
4. An 88-year-old who has right-sided paralysis and wants to be helped to the
bathroom immediately.
The Situation: The nurse is caring for these patients.
The Question: Who should the nurse see first?
Answer – The 45-years old with pneumonia and shortness of breath.
10. The Patients:
1. A 13-year-old female with a kidney infection who reports that there is “lots of
blood” in her urine.
2. An 18-year-old male with acute alcohol poisoning who is seeing “bugs on the
walls.”
3. A 21-year-old female with inflammatory bowel disease who has soaked a dressing
three hours after surgery.
4. A 25-year old male who is sobbing in his room after being told that he has
testicular cancer.
The Situation: The nurse is caring for these four patients.
The Question: Who should the nurse see first?
Answer – The 21-years old who is three hours postoperative and has a soaked
dressing.
11. The Patients:
1. A 42-year-old with diabetes who is blind and is asking to get up and moved to a
chair.
2. An 88-year-old with lower body paralysis who wants to be turned in bed.
3. A 17-year-old with asthma who smokes and has been in the bathroom for 30
minutes.
4. A 55-year-old with cardiac disease who tells the nurse, “Get the TV fixed or I am
leaving this place.”
The Situation: The nurse is caring for these four patients.
The Question: Which patient should the nurse see first?
Answer – The 17-year old with asthma who may be smoking in the bathroom.
12. The Patient: An elderly female accompanied by her middle-aged son.
The Situation: The patient is being discharged after 15-day stay on the medical unit,
and the son offers the nurse a box of candy as a gesture of thanks for caring for his
mother.
The Question: What should the nurse do in response to the offer of this gift?
Answer – Sincerely thank the son, and share the candy with all staff member on the
unit.
13. The Patient: A 25-year-old female who has smoked since age 12.
The Situation: The patient is complaining of “skipped heart beats.”
The Question: Which instruction is most important for the nurse to provide this
patient?
Answer – Call for assistance if she feels weak or dizzy when getting out of bed.
14. The Patient: A frail 88-year-old male who has recently become slightly confused.
The Situation: The nurse is making a home visit and assesses the safety features of the
home environment.
The Question: Which suggestion would be most important for the nurse to provide the
family?
Answer – Eliminate any throw rugs from floor.
15. The Patient: A 55-year-old female with a family history of hypertension.
The Situation: The patient is concerned about her health and states, “I have had severe
headaches for the last six months. I think I might have high blood pressure.” The
nurse determines that the woman’s blood pressure is 138/86 (high normal).
The Question: What action would be best for the nurse to take?
Answer – Ask the patient about the frequency, timing and quality of her headaches.
16. The Patient: A 35-year-old female with a history of asthma.
The Situation: The patient has been using a steroid inhaler because she is short of
breath. However, she states that her shortness of breath is “no better.”
The Question: What is the most important information for the nurse to obtain?
Answer – Method of using the inhaler.
17. The Patient: An older confused male.
The Situation: At 3 a.m. the patient, who thinks he is in the bathroom, defecates in the
bed. The bed needs to be changed. However, there are no bed sheets on the nursing
unit.
The Question: What action should the nurse take first?
Answer – Ask a nursing assistant to go to another unit and borrow linen.
18. The Patient: A 25-year-old female hospitalized for anorexia.
The Situation: The charge nurse denies the patient permission to pass dinner trays.
The Question: What is the most important reason for the nurse to deny this anorexic
patient permission to pass the dinner trays?
Answer – Treatment protocol for anorexics mandates that they avoid preoccupation
with food.
19. The Patient: A 75-year-old male who had a heart attack four years ago.
The Situation: The patient tells the nurse, “Even though I stopped smoking 10 years
ago, I have a terrible cough.”
The Question: What action should the nurse take first?
Answer – Auscultate all lung fields
20. The Patient: A 70-year-old man dying of prostate cancer.
The Situation: Nurse “A,” who is charge of a medical unit, notices that a dying patient
continues to moan in pain after receiving intravenous injections of morphins
whenever Nurse “B” is caring for him. Nurse “A” suspects that Nurse “B” may be
diluting the patient’s dose and taking the morphine to feed an addiction.
The Question: What should Nurse “A” do in this situation?
Answer – Notify the shift supervisor and unit director of the circumstances before
taking action
21. The Patient: A 29-year-old male.
The Situation: A lower leg cast was applied yesterday to a fractured leg. Today the
patient tells the nurse that he is in “terrible pain.”
The Question: Which action is most important for the nurse to take?
Answer – Check the patient’s toes for adequate circulation.
22. The Patient: A 54-year-old male who weighs 275 pounds. He is 5’ 10” tall and has
many family members who have died of heart disease.
The Situation: He comes to the clinic stating that he has had several episodes of
“chest pain” in the last week.
The Question: What is the most important action for the nurse to take?
Answer – Ask the patient to describe the chest pain.
23. The Patient: A 7-year-old child.
The Situation: A nurse arrives with an injection containing preoperative sedation that
must be given to the child now. The child asks the nurse if the shot will hurt.
The Question: What response should the nurse offer to this child?
Answer – “Yes, but it won’t last very long and soon you will be sleepy”
24. The Patient: A 35-year-old female.
The Situation: The patient is admitted with a diagnosis of abdominal pain and
diarrhea.
The Question: Which action should the nurse take first?
Answer – Initiate Intravenous fluids.
25. The Patient: A 51-year-old male.
The Situation: The patient is pale, has dark circles under his eyes, and responds to
questions with a soft, low voice. He tells the nurse that he has not slept well for
months, but denies any type of pain.
The Question: What information is most important for the nurse to obtain?
Answer – The existence of a significant life in the last year that has caused anxiety.
26. The Patient: A 19-year-old male who has previously been healthy.
The Situation: The patient complains that he is losing weight despite “eating all the
time.”
The Question: Considering this patient’s age and complaint, which diagnostic test is
likely to provide the most important information?
Answer – A fingerstick for blood sugar level.
27. The Patient: An adult with diabetes mellitus who was just given a morning does of
insulin which lowers the blood sugar.
The Situation: The patient’s breakfast tray arrives, and the nurse notices that the
pancake syrup and sugar packets have not been substituted with products containing
artificial sweeteners.
The Question: What should the nurse do first in this situation?
Answer – Remove foods containing sugar and offer sugar substitutes.
28. The Patient: A terminally ill male.
The Situation: Nurse “A” and an unidentified woman ride the elevator to the fifth
floor, Nurse “B” joins them on the elevator and exclaims that a code has just been
called on a male patient on the fifth floor, and he is not expected to live.
The Question: What should Nurse “A” do in this situation?
Answer – Tell Nurse B stop discussing the client’s situation in a public place.
29. The Patient: An elderly confused female in a semi-private room on a hospital medical
unit.
The Situation: The patient is yelling loudly at 3:30a.m. and awakens her roommate,
who calls the nurse for assistance.
The Question: What should the nurse do first in this situation?
Answer – Assess the confused patient for causes of her behaviour.
30. The Patient: A 75-year-old male.
The Situation: The family brings the patient to the emergency room because they
witnessed him have a seizure. The patient is hallucinating, and loudly cries out to the
nurse, “Get those dogs out of here!” The nurse places the patient in a cubicle where he
can be seen from the nurse’s station.
The Question: What action would be best for the nurse to take?
Answer – Ask the family to remain with the patient.
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 observesthat 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.
11. The nurse is instructing a client with high cholesterol about diet and life style modification.
What comment from the client indicates that the teaching has been effective?
I will limit my intake of beef to 4 ounces per week.
12. The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest
way to transfer an elderly client with left-sided weakness from the bed to the chair. What
method describes the correct transfer procedure for this client?
Move the chair parallel to the right side of the bed, and stand the client on the right foot.
13. An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to
administering a soap suds enema. Which instruction should the nurse provide the UAP?
Reposition in a Sim's position with the client's weight on the anterior ilium.
14. A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should
the nurse have for planning care in terms of the client's beliefs?
Blood transfusions are forbidden.
15. The nurse observes that a male client has removed the covering from an ice pack applied
to his knee. What action should the nurse take first?
Observe the appearance of the skin under the ice pack. [Show Less]