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HESI A2 - Critical Thinking Questions and Answers | Latest Version | 2025/2026 | Correct & Verified
A patient suddenly develops shortness of breath and chest pain. What should the nurse do first?
- Notify the provider immediately
- Administer a PRN pain medication
- Ask the patient about their pain history
✔✔B. Assess vital signs and oxygen saturation
A client is found on the floor after attempting to get out of bed unassisted. What is the nurse’s first action?✔✔A. Assess the client for injury
- Call the provider
- Fill out an incident report
- Reassure the client
A patient reports severe abdominal pain rated 9/10 but has stable vital signs. What is the nurse’s first step? 1 / 4
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✔✔A. Further assess location, quality, and characteristics of the pain
- Administer the strongest available pain medication
- Call the healthcare provider
- Document the pain score only
A nurse finds a medication error before giving the drug. What should the nurse do first?✔✔A. Withhold the medication and verify the order
- Administer it as prescribed
- Document the error in the chart
- Report the error to pharmacy
A client is confused and repeatedly tries to pull out their IV. What should the nurse do first?✔✔A. Redirect the client and provide close observation
- Apply wrist restraints immediately
- Remove the IV line
- Call the family
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A patient is scheduled for surgery but states, “I don’t really understand why I need this.” What is the nurse’s best action?✔✔A. Notify the surgeon to explain the procedure again
- Provide a detailed explanation of the surgery
- Reassure the patient it is routine
- Continue preparing the patient for surgery
While caring for four patients, which should the nurse assess first?
- A client requesting a sleeping pill
- A client who needs discharge instructions
- A client asking for pain medication for chronic back pain
✔✔B. A client with wheezing and shortness of breath
A patient on the medical unit is due for their 9 AM medication, but their blood pressure is 88/56.The order is for a beta-blocker. What should the nurse do first?✔✔A. Hold the medication and recheck the blood pressure
- Give the medication as prescribed
- Call the provider without rechecking 3 / 4
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- Document “not given” only
A nurse enters a room and sees the IV pump alarming. What is the first step?✔✔A. Assess the IV site and tubing for problems
- Silence the alarm immediately
- Call maintenance
- Restart the infusion without checking
A client with diabetes is shaky, sweaty, and confused. What should the nurse do first?✔✔A. Check blood glucose
- Notify the provider
- Offer water
- Document symptoms
The nurse finds a patient crying and withdrawn. What is the best action?
- Leave the room for privacy
- Tell the patient not to worry
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✔✔C. Sit quietly and allow the patient to share feelings