HESI A2 - Critical Thinking- Rationale
. The nurse is working in the emergency department (ED) of a children's medical center. Which client should
... [Show More] 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
Correct - 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.
. 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
Correct - 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.
. 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
Correct -1. The nurse should always praise the child for attempts at cooperation even if the child did not accomplish what the nurse asked.
. 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 level of 180 mg/dL.
2. The child diagnosed with pneumonia who is coughing and has a temperature of 100°F.
3. The child diagnosed with gastroenteritis who has a potassium (K+) level of 3.9 mEq/L.
4. The child diagnosed with cystic fibrosis who has a pulse oximeter reading of 90%. Rationale
Correct - 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.
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 with methicillin-resistant Staphylococcus aureus (MRSA).
2. The IVP steroid methylprednisolone (Solu-Medrol) to the child diagnosed with asthma [Show Less]