HESI Critical Thinking Questions and Answers
1. The nurse is working in the emergency department (ED) of a children's medical center. Which
client shoul
... [Show More] d the nurse assess first?
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.
2. 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?
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.
3. 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?
Correct -1. The nurse should always praise the child for attempts at cooperation even if the child
did not accomplish what the nurse asked.
4. The nurse is caring for clients on the pediatric medical unit. Which client should the nurse
assess first?
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.
5. The nurse has received the a.m. shift report for clients on a pediatric unit. Which medication
should the nurse administer first?
Correct - 3-Sliding scale insulin is ordered ac, which is before meals; therefore, this medication
must be administered first after receiving the a.m. shift report.
4-Routine medications have a 1-hour leeway before and after the scheduled time; therefore, this
medication does not have to be adminis- tered first.
6. A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which
information should the nurse collect before this procedure?
D. Reactions to previous hospitalizations
Rationale
Assess how the child reacted to hospitalization and any complications. If the child reacted
poorly, he or she may be afraid now and will need special preparation for the examination that is
to follow. The other items are not significant for the procedure
7. A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently
sleeping. What should the nurse do first when beginning the examination?
) Auscultate the lungs and heart while the infant is still sleeping.
Rationale
When the infant is quiet or sleeping is an ideal time to assess the cardiac, respiratory, and
abdominal systems. Assessment of the eye, ear, nose, and throat are invasive procedures and
should be performed at the end of the examination.
6. The nurse enters the client's room and realizes the 9-month-old infant is not breath- ing.
Which interventions should the nurse implement? Prioritize the nurse's actions from first (1) to
last (5). [Show Less]