HOSMERIT
HESI/SAUNDERS REVIEW EXAM QUESTIONS AND
100% CORRECT ANSWERS A+ GRADE
A nurse is teaching the mother of a child with diarrhea about signs and symptoms that require a
call to the physician. Which of the following statements by the mother indicates a need for further
instruction?
a. "I'll call the doctor if she gets dizzy and acts sick."
b. "I'll call the doctor if she has severe stomach cramps."
c. "I'll call the doctor if her temperature is 102° or higher."
d. "I'll call the physician if she goes longer than 6 hours without urinating." Answer : C
Rationale: The mother should call the physician if a fever over 100° F, especially one lasting
longer than 72 hours, develops. She should not wait until the temperature climbs to 102° F. The
remaining statements are all correct because the findings suggest possible dehydration and
hypovolemia. In addition, severe abdominal cramps could indicate an acute problem.
A nurse is going to administer a vitamin K injection to a newborn. To which of the following
sites will the nurse administer the medication?
a. area of greater trochanter
b. area of the femoral vein
c. lateral aspect of the middle third of the vastus lateralis
d. patellar area - Answer: 3
Rationale: The site of choice for vitamin K injection in the newborn is the lateral aspect of the
middle third of the vastus lateralis muscle - the middle third of the infant's thigh. It is the site of
choice because it does not contain major blood vessels and nerves and is big enough to take up the
medication. Option 1 is the area of the greater trochanter.
Option 2 reflects the area of the femoral vein. Option 4 indicates the area of the patella.
A nurse utilizing a medical history for an infant diagnosed with gastroesophageal reflux would
anticipate noting the presence of:
,a. Refusal to suck Incorrect
b. Frequent diarrhea
c. Recurrent otitis media
d. Inability to pass stools - Answer: C
Rationale: GER is the retrograde movement of gastric contents into the esophagus. The three
types of GER include physiologic, functional, and pathologic. Vomiting or spitting up after
feeding, hiccupping, and recurrent otitis media related to pooling of secretions in the nasopharynx
during sleep are common to all three types of GER. Fussiness and refusal to suck, diarrhea, and
inability to pass stools are not related to GER.
Caring for a child admitted to the hospital with Kawasaki disease, the nurse should monitor the
child most closely for signs of:
a. Anemia
b. Renal failure
c. Thrombus formation
d. Gastrointestinal disturbances - Answer: C
Rationale: Kawasaki disease, also called mucocutaneous lymph node syndrome, is an acute
febrile exanthematous illness of children with a generalized vasculitis of unknown origin. A
generalized immune response involves the smooth muscle cells of the vascular walls. These
vascular changes, in concert with the increase in platelets that occurs as a part of the disease,
may result in thrombus formation, myocardial infarction, and death in some children. Anemia,
renal failure, and gastrointestinal disturbances are not specifically associated with this disorder.
A nurse is providing dietary instructions to the mother of a child diagnosed with
iron-deficiency anemia. The nurse should inform the mother that the following food is highest
in iron:
a. Milk
b. Cheese
c. Orange juice
,d. Cream of Wheat - Answer: D
Rationale: Iron-rich foods include liver, dried beans, Cream of Wheat, iron-fortified cereal,
apricots and prunes (and other dried fruits), egg yolks, and dark-green leafy vegetables. Foods
rich in calcium include milk and cheese. Orange juice is rich in vitamin C.
A nurse is teaching a teenager patient with sickle cell disease about the ways to prevent vaso-
occlusive crisis. The nurse should teach the client to:
a. Restrict fluid intake
b. Ibuprofen (Motrin) may be given for discomfort
c. Immediately give acetylsalicylic acid (aspirin) once a fever has started
d. Patient must spend a lot of time in fresh air and sun daily - Answer: B
Rationale: The adolescent with sickle cell disease is treated with the recommendation to take
acetaminophen (Tylenol) or ibuprofen (Motrin) if discomfort occurs. The use of aspirin is
avoided. Instruct the adolescent to call the physician if a fever develops. Avoid dehydration by
instructing the adolescent to consume adequate fluids. Also avoid cold and heat stress and
prolonged exposure to the sun because it may cause dehydration, which can precipitate a crisis.
A nurse is reviewing the record of a child suspected of having acute poststreptococcal
glomerulonephritis and notes that the child recently had a streptococcal throat infection treated
with antibiotics. Which of the following physician prescriptions that will confirm the diagnosis of
acute poststreptococcal glomerulonephritis does the nurse expect to find?
a. Throat culture
b. Blood urea nitrogen (BUN)
c. Antistreptolysin (ASO) titer
d. White blood cell (WBC) count - Answer: C
Rationale: Immunologic studies are helpful in the diagnosis of acute poststreptococcal
glomerulonephritis. The ASO titer, representing antibodies to the streptococcal bacteria, may be
elevated. Culture of the throat may be useful in identifying the bacterium; however, this test is
helpful only if the infection is acute and the child has not received antibiotics. The BUN level
would be elevated if renal insufficiency was occurring. The WBC count is usually normal. Throat
, culture, BUN and WBC count would not confirm the diagnosis of acute poststreptococcal
glomerulonephritis.
The nurse is caring for the client who begins to seize while in bed. Which of the following
actions does the nurse perform in caring for the client? Select all that apply.
a. Observing and timing the seizure
b. Loosening any restrictive clothing
c. Placing the client in a side-lying position
d. Removing the side rail pads
e. Placing an airway in the client's mouth
f. Clearing the surrounding area of objects that may cause injury to the client - Answer: A, B, C,
F
Rationale: Safety of the client having the seizure is a concern for the client. Nursing actions
during a seizure include providing privacy, loosening restrictive clothing, removing the pillow,
raising the padded side rails on the bed, removing objects that might cause injury to the client, and
placing the client on the side with the head flexed forward if possible, to allow the tongue to fall
forward and facilitate drainage. (The nurse should not put anything into the client's mouth.) The
nurse also observes, documents, and times the seizure. If the client is not in bed when seizure
activity starts, the nurse moves the client to the floor, if possible; cushions the head to prevent
injury; and repositions furniture that may injure the client if he or she comes into contact with it
during the seizure.
Which of the following infection-control measures would the nurse implement for a client in
whom smallpox is diagnosed?
a. Enteric
b. Droplet
c. Contact
d. Standard
e. Protective isolation - Answer: B, C, E
HESI/SAUNDERS REVIEW EXAM QUESTIONS AND
100% CORRECT ANSWERS A+ GRADE
A nurse is teaching the mother of a child with diarrhea about signs and symptoms that require a
call to the physician. Which of the following statements by the mother indicates a need for further
instruction?
a. "I'll call the doctor if she gets dizzy and acts sick."
b. "I'll call the doctor if she has severe stomach cramps."
c. "I'll call the doctor if her temperature is 102° or higher."
d. "I'll call the physician if she goes longer than 6 hours without urinating." Answer : C
Rationale: The mother should call the physician if a fever over 100° F, especially one lasting
longer than 72 hours, develops. She should not wait until the temperature climbs to 102° F. The
remaining statements are all correct because the findings suggest possible dehydration and
hypovolemia. In addition, severe abdominal cramps could indicate an acute problem.
A nurse is going to administer a vitamin K injection to a newborn. To which of the following
sites will the nurse administer the medication?
a. area of greater trochanter
b. area of the femoral vein
c. lateral aspect of the middle third of the vastus lateralis
d. patellar area - Answer: 3
Rationale: The site of choice for vitamin K injection in the newborn is the lateral aspect of the
middle third of the vastus lateralis muscle - the middle third of the infant's thigh. It is the site of
choice because it does not contain major blood vessels and nerves and is big enough to take up the
medication. Option 1 is the area of the greater trochanter.
Option 2 reflects the area of the femoral vein. Option 4 indicates the area of the patella.
A nurse utilizing a medical history for an infant diagnosed with gastroesophageal reflux would
anticipate noting the presence of:
,a. Refusal to suck Incorrect
b. Frequent diarrhea
c. Recurrent otitis media
d. Inability to pass stools - Answer: C
Rationale: GER is the retrograde movement of gastric contents into the esophagus. The three
types of GER include physiologic, functional, and pathologic. Vomiting or spitting up after
feeding, hiccupping, and recurrent otitis media related to pooling of secretions in the nasopharynx
during sleep are common to all three types of GER. Fussiness and refusal to suck, diarrhea, and
inability to pass stools are not related to GER.
Caring for a child admitted to the hospital with Kawasaki disease, the nurse should monitor the
child most closely for signs of:
a. Anemia
b. Renal failure
c. Thrombus formation
d. Gastrointestinal disturbances - Answer: C
Rationale: Kawasaki disease, also called mucocutaneous lymph node syndrome, is an acute
febrile exanthematous illness of children with a generalized vasculitis of unknown origin. A
generalized immune response involves the smooth muscle cells of the vascular walls. These
vascular changes, in concert with the increase in platelets that occurs as a part of the disease,
may result in thrombus formation, myocardial infarction, and death in some children. Anemia,
renal failure, and gastrointestinal disturbances are not specifically associated with this disorder.
A nurse is providing dietary instructions to the mother of a child diagnosed with
iron-deficiency anemia. The nurse should inform the mother that the following food is highest
in iron:
a. Milk
b. Cheese
c. Orange juice
,d. Cream of Wheat - Answer: D
Rationale: Iron-rich foods include liver, dried beans, Cream of Wheat, iron-fortified cereal,
apricots and prunes (and other dried fruits), egg yolks, and dark-green leafy vegetables. Foods
rich in calcium include milk and cheese. Orange juice is rich in vitamin C.
A nurse is teaching a teenager patient with sickle cell disease about the ways to prevent vaso-
occlusive crisis. The nurse should teach the client to:
a. Restrict fluid intake
b. Ibuprofen (Motrin) may be given for discomfort
c. Immediately give acetylsalicylic acid (aspirin) once a fever has started
d. Patient must spend a lot of time in fresh air and sun daily - Answer: B
Rationale: The adolescent with sickle cell disease is treated with the recommendation to take
acetaminophen (Tylenol) or ibuprofen (Motrin) if discomfort occurs. The use of aspirin is
avoided. Instruct the adolescent to call the physician if a fever develops. Avoid dehydration by
instructing the adolescent to consume adequate fluids. Also avoid cold and heat stress and
prolonged exposure to the sun because it may cause dehydration, which can precipitate a crisis.
A nurse is reviewing the record of a child suspected of having acute poststreptococcal
glomerulonephritis and notes that the child recently had a streptococcal throat infection treated
with antibiotics. Which of the following physician prescriptions that will confirm the diagnosis of
acute poststreptococcal glomerulonephritis does the nurse expect to find?
a. Throat culture
b. Blood urea nitrogen (BUN)
c. Antistreptolysin (ASO) titer
d. White blood cell (WBC) count - Answer: C
Rationale: Immunologic studies are helpful in the diagnosis of acute poststreptococcal
glomerulonephritis. The ASO titer, representing antibodies to the streptococcal bacteria, may be
elevated. Culture of the throat may be useful in identifying the bacterium; however, this test is
helpful only if the infection is acute and the child has not received antibiotics. The BUN level
would be elevated if renal insufficiency was occurring. The WBC count is usually normal. Throat
, culture, BUN and WBC count would not confirm the diagnosis of acute poststreptococcal
glomerulonephritis.
The nurse is caring for the client who begins to seize while in bed. Which of the following
actions does the nurse perform in caring for the client? Select all that apply.
a. Observing and timing the seizure
b. Loosening any restrictive clothing
c. Placing the client in a side-lying position
d. Removing the side rail pads
e. Placing an airway in the client's mouth
f. Clearing the surrounding area of objects that may cause injury to the client - Answer: A, B, C,
F
Rationale: Safety of the client having the seizure is a concern for the client. Nursing actions
during a seizure include providing privacy, loosening restrictive clothing, removing the pillow,
raising the padded side rails on the bed, removing objects that might cause injury to the client, and
placing the client on the side with the head flexed forward if possible, to allow the tongue to fall
forward and facilitate drainage. (The nurse should not put anything into the client's mouth.) The
nurse also observes, documents, and times the seizure. If the client is not in bed when seizure
activity starts, the nurse moves the client to the floor, if possible; cushions the head to prevent
injury; and repositions furniture that may injure the client if he or she comes into contact with it
during the seizure.
Which of the following infection-control measures would the nurse implement for a client in
whom smallpox is diagnosed?
a. Enteric
b. Droplet
c. Contact
d. Standard
e. Protective isolation - Answer: B, C, E
