HESI A2 V1- Critical Thinking Questions and correct solutions
The Patient: A 65-year-old man.
The Situation- The family brings the patient to the
... [Show More] emergency room because he just took an entire bottle of pills.
The Question: What action should the nurse take first?
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 night when he developed severe shortness of breath on the way to the bathroom.
The Question: What action should the nurse take first?
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?
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?
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 do obtain information about which previous occurrence?
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?
The Patient: A 70-year-old male who is relatively healthy.
The Situation: A liquid medication is prescribed for this patient.
The Question: Prior to administering the prescribed medication, what intervention has the highest priority?
The Patient: A 50-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?
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. A 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?
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?
The Patient:
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?
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?
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?
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? 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 (hight normal).
The Question: What action would be best for the nurse to take? [Show Less]