Evolve HESI peds Practice Questions Save
Terms in this set (85)
A 6-month-old infant with congestive heart Apical heart rate of 60.
failure (CHF) is receiving digoxin elixir.
Which observation by the nurse warrants A heart rate of 60 (A) is much lower than normal for a 6-
immediate intervention? month-old and warrants immediate intervention. The normal
Apical heart rate of 60. heart rate for a 6-month-old is 80 to 150 BPM when awake,
Sweating across the forehead. and a rate of 70 while sleeping is considered within normal
Doesn't suck well. limits. (B and C) are expected symptoms of heart failure in an
Respiratory rate of 30 breaths per minute. infant. (D) is within normal limits for an infant.
,The nurse is teaching the parents of a 5- Administer aerosol therapy followed by postural drainage
year-old with cystic fibrosis about before meals.
respiratory treatments. Which statement
indicates to the nurse that the parents Postural drainage for a child with cystic fibrosis is most
understand? effective when performed after nebulization and before
Perform postural drainage before starting meals (C) or at least 1 hour after eating to prevent nausea
aerosol therapy. and vomiting. Postural drainage uses gravity to promote
Give respiratory treatments when the child mucous removal after nebulization (A) treatments which
is coughing a lot. open the airways. Pulmonary toileting or respiratory
Administer aerosol therapy followed by treatments should be given 3 to 4 times daily, not
postural drainage before meals. episodically (B and D).
Ensure respiratory therapy is done daily
during any respiratory infection.
A female teenager is taking oral Use sunscreen when lying by the pool.
tetracycline HCL (Achromycin V) for acne
vulgaris. What is the most important Photosensitivity is a common side effect of tetracycline HCL
instruction for the nurse to include in this (Achromycin V) therapy. Severe sunburn can occur with
client's teaching plan? minimal sun exposure and clients should be instructed to
Use sunscreen when lying by the pool. avoid sunlight and to use sunscreen (A). (B and D) are not
Cleanse the skin at least 4 times a day. related to tetracycline HCL (Achromycin V) therapy. (C)
Take the medication with a glass of milk. should be avoided because dairy products interfere with the
Menstrual periods may become irregular. absorption of tetracyclines.
,What preoperative nursing intervention Observe for projectile vomiting.
should be included in the plan of care for
an infant with pyloric stenosis? Projectile vomiting (D), which contributes to metabolic
Monitor for signs of metabolic acidosis. alkalosis (A), is the classic sign of pyloric stenosis. (B) is not
Estimate the quantity of diarrhea stools. indicated. (C) is dangerous, due to the potential for
Place in a supine position after feeding. aspiration with frequent vomiting.
Observe for projectile vomiting.
An infant is born with a ventricular septal Prevent the return of oxygenated blood to the lungs.
defect (VSD) and surgery is planned to
correct the defect. The nurse recognizes Closure of VSDs stops oxygenated blood from being
that surgical correction is designed to shunted from the left ventricle to the right ventricle (C). VSDs
achieve which outcome? are acyanotic defects, which means that no unoxygenated
Stop the flow of unoxygenated blood into blood enters the systemic circulation (A and B). (D) is
systemic circulation. common with Tetrology of Fallot, which is a cyanotic defect.
Increase the flow of unoxygenated blood
to the lungs.
Prevent the return of oxygenated blood to
the lungs.
Reduce peripheral tissue hypoxia and
nailbed clubbing
, A 3-week-old newborn is brought to the A. Monitor the the infant's weight and number of wet diapers
clinic for follow-up after a home birth. The per day.
mother reports that her child bottle feeds B. Increase the infant's intake per feeding by 1 to 2 ounces
for 5 minutes only and then falls asleep. The per week.
nurse auscultates a loud murmur D. Allow the infant to rest and refeed on demand or every 2
characteristic of a ventricular septal defect hours.
(VSD), and finds the newborn is acyanotic E. Use a softer nipple or increase the size of the nipple
with a respiratory rate of 64 breaths per opening.
minute. What instruction should the nurse
provide the mother to ensure the infant is Antibiotic prophylaxis is recommended for infants with VSDs,
receiving adequate intake? (Select all that but should not be mixed in a bottle of formula (C) because it
apply.) is difficult to ensure that the total dose is consumed.
A. Monitor the the infant's weight and
number of wet diapers per day. They should be monitored for weight gain and at least 6 wet
B. Increase the infant's intake per feeding diapers per day (A). A one-month old infant should ingest 2
by 1 to 2 ounces per week. to 4 ounces of formula per feeding and progress to about 30
C. Mix the dose of prophylactic antibiotic in ounces per day by 4-months of age (B)
a full bottle of formula.
D. Allow the infant to rest and refeed on
demand or every 2 hours.
E. Use a softer nipple or increase the size
of the nipple opening.
Terms in this set (85)
A 6-month-old infant with congestive heart Apical heart rate of 60.
failure (CHF) is receiving digoxin elixir.
Which observation by the nurse warrants A heart rate of 60 (A) is much lower than normal for a 6-
immediate intervention? month-old and warrants immediate intervention. The normal
Apical heart rate of 60. heart rate for a 6-month-old is 80 to 150 BPM when awake,
Sweating across the forehead. and a rate of 70 while sleeping is considered within normal
Doesn't suck well. limits. (B and C) are expected symptoms of heart failure in an
Respiratory rate of 30 breaths per minute. infant. (D) is within normal limits for an infant.
,The nurse is teaching the parents of a 5- Administer aerosol therapy followed by postural drainage
year-old with cystic fibrosis about before meals.
respiratory treatments. Which statement
indicates to the nurse that the parents Postural drainage for a child with cystic fibrosis is most
understand? effective when performed after nebulization and before
Perform postural drainage before starting meals (C) or at least 1 hour after eating to prevent nausea
aerosol therapy. and vomiting. Postural drainage uses gravity to promote
Give respiratory treatments when the child mucous removal after nebulization (A) treatments which
is coughing a lot. open the airways. Pulmonary toileting or respiratory
Administer aerosol therapy followed by treatments should be given 3 to 4 times daily, not
postural drainage before meals. episodically (B and D).
Ensure respiratory therapy is done daily
during any respiratory infection.
A female teenager is taking oral Use sunscreen when lying by the pool.
tetracycline HCL (Achromycin V) for acne
vulgaris. What is the most important Photosensitivity is a common side effect of tetracycline HCL
instruction for the nurse to include in this (Achromycin V) therapy. Severe sunburn can occur with
client's teaching plan? minimal sun exposure and clients should be instructed to
Use sunscreen when lying by the pool. avoid sunlight and to use sunscreen (A). (B and D) are not
Cleanse the skin at least 4 times a day. related to tetracycline HCL (Achromycin V) therapy. (C)
Take the medication with a glass of milk. should be avoided because dairy products interfere with the
Menstrual periods may become irregular. absorption of tetracyclines.
,What preoperative nursing intervention Observe for projectile vomiting.
should be included in the plan of care for
an infant with pyloric stenosis? Projectile vomiting (D), which contributes to metabolic
Monitor for signs of metabolic acidosis. alkalosis (A), is the classic sign of pyloric stenosis. (B) is not
Estimate the quantity of diarrhea stools. indicated. (C) is dangerous, due to the potential for
Place in a supine position after feeding. aspiration with frequent vomiting.
Observe for projectile vomiting.
An infant is born with a ventricular septal Prevent the return of oxygenated blood to the lungs.
defect (VSD) and surgery is planned to
correct the defect. The nurse recognizes Closure of VSDs stops oxygenated blood from being
that surgical correction is designed to shunted from the left ventricle to the right ventricle (C). VSDs
achieve which outcome? are acyanotic defects, which means that no unoxygenated
Stop the flow of unoxygenated blood into blood enters the systemic circulation (A and B). (D) is
systemic circulation. common with Tetrology of Fallot, which is a cyanotic defect.
Increase the flow of unoxygenated blood
to the lungs.
Prevent the return of oxygenated blood to
the lungs.
Reduce peripheral tissue hypoxia and
nailbed clubbing
, A 3-week-old newborn is brought to the A. Monitor the the infant's weight and number of wet diapers
clinic for follow-up after a home birth. The per day.
mother reports that her child bottle feeds B. Increase the infant's intake per feeding by 1 to 2 ounces
for 5 minutes only and then falls asleep. The per week.
nurse auscultates a loud murmur D. Allow the infant to rest and refeed on demand or every 2
characteristic of a ventricular septal defect hours.
(VSD), and finds the newborn is acyanotic E. Use a softer nipple or increase the size of the nipple
with a respiratory rate of 64 breaths per opening.
minute. What instruction should the nurse
provide the mother to ensure the infant is Antibiotic prophylaxis is recommended for infants with VSDs,
receiving adequate intake? (Select all that but should not be mixed in a bottle of formula (C) because it
apply.) is difficult to ensure that the total dose is consumed.
A. Monitor the the infant's weight and
number of wet diapers per day. They should be monitored for weight gain and at least 6 wet
B. Increase the infant's intake per feeding diapers per day (A). A one-month old infant should ingest 2
by 1 to 2 ounces per week. to 4 ounces of formula per feeding and progress to about 30
C. Mix the dose of prophylactic antibiotic in ounces per day by 4-months of age (B)
a full bottle of formula.
D. Allow the infant to rest and refeed on
demand or every 2 hours.
E. Use a softer nipple or increase the size
of the nipple opening.
