HESI A2 - CRITICAL THINKING- RATIONALE EXAM

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HESI A2 - CRITICAL THINKING- RATIONALE EXAM

QUESTIONS

Actual Qs and Ans Expert-Verified Explanation

This Exam contains:

-Guarantee passing score -95 Questions and Answers -format set of multiple-choice -Expert-Verified Explanation Question 1: 60. The nurse is caring for clients on a psychiatric pediatric unit. Which action by the nurse is reportable to the state board of nursing?

• The nurse leaves for lunch and does not return to complete the shift.
• The nurse fails to check the ID band when administering medications.
• The nurse has had three documented medication errors in the last 3 months.
• The nurse has admitted to having an affair with another staff member.

Answer:

**1. Abandonment is a reportable offense to the state board of nursing in every state. Reportable offenses could result in stipulations made to the nurse's license.

• This is failure to follow the five rights of medication administration, but it is not a reportable offense.

• Multiple medication errors are a manage- ment issue, not a reportable offense.

4.Having an affair with a fellow employee is not a reportable offense.

Question 2: 22. The charge nurse is making shift assignments on a pediatric oncology unit.Which delegation/assignment would be most appropriate?

• Delegate the unlicensed assistive personnel (UAP) to obtain routine blood work

from the central line.

• Instruct the licensed practical nurse (LPN) to contact the leukemia support group.
• Assign the chemotherapy-certified RN to administer chemotherapeutic medication.
• Have the dietitian check the meal trays for the amount eaten.

Answer:

1-Only an RN can withdraw blood from a central line.

• The social worker or case manager is respon-

sible for referring clients to support groups. This is not an expected responsibility of a floor nurse/LPN.**3. Only chemotherapy-certified RNs can administer antineoplastic, chemothera- peutic medications.This is a national minimal standard of care according to the Oncology Nursing Society.

• The dietician is responsible for ensuring that the proper food is provided along with evalu- ating the

child's nutritional intake, not checking the amount of food eaten-this is the responsibility of the nursing staff.Question 3: The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain?

• All patients will behave the same way when in pain.
• Just as patients vary in their perceptions of pain, so will they vary in their expressions of

pain.

• Cultural norms have very little to do with pain tolerance, because pain tolerance is always

biologically determined.

• A patient's expression of pain is largely dependent on the amount of tissue injury associated

with the pain.

Answer:

• Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain.

Rationale In addition to expecting variations in pain perception and tolerance, the nurse should expect variations in the expression of pain. It is well known that individuals turn to their social environment for validation and comparison. The other statements are incorrect.

Question 4: 58. The home health nurse is planning the care of a 14-year-old client diagnosed with leukemia who is receiving chemotherapy. Which psychosocial problem is priority for this client?

• Diversional activity deficit.
• High risk for infection.
• Social isolation.
• Hopelessness.

Answer:

• Diversional activity deficit would be appro- priate if the client did not have sufficient activities to keep

him or her occupied. Most children of this age will watch television, play video games, or read books.

• The client has leukemia and is receiving chemotherapy, which leads to an increased risk of infection;

however, this is a physiolog- ical problem, not a psychosocial problem.**3. The client will be isolated from peers and schools because of the high risk of infec- tion resulting from the immunosuppres- sion secondary to chemotherapy and the disease process. At this stage, the child needs to be developing peer relationships and independence from parents. There- fore, social isolation is the priority psy- chosocial problem for this client.

• The nurse should not identify hopelessness because childhood leukemia has a good prognosis.

Question 5: An elderly Mexican-American woman with traditional beliefs has been admitted to

an inpatient care unit. A culturally-sensitive nurse would:

• contact the hospital administrator about the best course of action.
• automatically get a curandero for her because it is not culturally appropriate for her to

request one.

• further assess the patient's cultural beliefs and offer the patient assistance in contacting a

curandero or priest if she desires.

• ask the family what they would like to do because Mexican-Americans traditionally give

control of decisions to their families.

Answer:

• further assess the patient's cultural beliefs and offer the patient assistance in contacting a curandero

or priest if she desires.Rationale In addition to seeking help from the biomedical/scientific health care provider, patients may also seek help from folk or religious healers. Some people, such as those of Mexican-American or American Indian origins, may believe that the cure is incomplete unless the body, mind, and spirit are also healed

(although the division of the person into parts is a Western concept).Question 6: 29. The nurse is discharging a 4-month-old child with a temporary colostomy.Which intervention should the nurse implement?

• Request the UAP to complete the discharge written documentation.
• Tell the LPN to show the parent how to irrigate the colostomy.
• Ask the UAP to remove the child's intravenous catheter.
• Request the UAP to escort the parent and child to the car.

Answer:

1-The nurse cannot delegate teaching to the UAP.2-The LPN could teach a client how to irrigate a colostomy, but a 4-month-old is inconti- nent of stool; therefore, irrigating the colostomy is not done.3-The LPN or nurse should remove the IV catheter of a 4-month-old child, not the UAP.**4-The UAP can escort the child and parents to the car.Question 7: 37. The clinic nurse is discussing a tubal ligation with a 17-year-old adolescent with Down syndrome. The adolescent does not want the surgery, but her parents (who are also in the room) are telling her she must have it. Which statement by the nurse would be an example of the ethical principle of justice?

• "I think this requires further discussion before scheduling this procedure."
• "You will not be able to have children after you have this procedure."
• "You should have this procedure because you could not care for a child."
• "You can refuse this procedure and your parents can't make you have it."

Answer:

**1. The ethical principle of justice is to treat all clients fairly, without regard to age, socioeconomic status, or any other vari- able, including clients with special needs. This statement supports the adolescent's right to her opinion even though she has Down syndrome.

2.If the adolescent needs clarification of the procedure, this would be an appropriate re- sponse, which is an example of the ethical principle of veracity or truth telling.

3.This statement is an example of the ethical principle of paternalism, in which the nurse knows what is best for the client.

4.This is an example of autonomy, in which the client has the right to self-determination. The Nuremburg Code of ethics specifically supports the rights of individuals with special needs against being forced to participate in procedures they do not want.