Hesi a2 critical thinking LATEST-ALL ANSWERS VERIFIED 100%

1. 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?
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?