NCLEX HESI RN PEDIATRICS EXAM | ALL QUESTIONS AND CORREC
HESI Comprehensive NCLEX-RN Practice (Pediatrics)
ANSWERS | GRADED A+ | VERIFIED ANSWERS |
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1. Which interventions should the nurse in- B, D, E
clude in the teaching plan for the mother of Rationale:
a 6-year-old who is experiencing encopresis Encopresis is fecal incontinence, usually as
secondary to a fecal impaction? (Select all the result of recurring fecal impaction and
that apply.) an enlarged rectum caused by chronic con-
stipation. Encopresis is managed through
A.Provide a low-fiber diet. bowel retraining with mineral oil, eliminat-
B.Administer mineral oil daily. ing dairy products, and initiating a regular
C.Decrease the daily fluids. toileting routine. A high-fiber diet, not op-
D.Eliminate dairy products. tion A, and increased daily fluids, not option
E.Initiate consistent toileting routine. C, are components of care for a child with
encopresis.
2. The nurse is planning postoperative care D
for a child who has had a cleft lip repair. Rationale:
What is the most important reason to mini- Prevention of stress on the lip suture line
mize this child's crying during the recovery is essential for optimum healing and the
period? cosmetic appearance of a cleft lip repair. Al-
though crying also causes options A, B, and
A.Tear formation increases salivation. C, these conditions do not create a problem
B. This behavior increases respirations. for the child with a cleft lip repair
C. Excessive hysteria can lead to vomiting.
D. Crying stresses the suture line.
3. A 6-month-old male infant is admitted to B
the post-anesthesia care unit with elbow Rationale:
restraints in place. He has an endotra- Removing restraints one at a time is safer
cheal tube and is ventilator-dependent but than option C. The infant should have the
will be extubated soon following recovery restrained extremities assessed frequent-
from anesthesia. Which nursing interven- ly for signs of neurologic or vascular im-
tion should be included in this child's plan pairment, and range-of-motion exercises
of care? should be performed with these assess-
, HESI Comprehensive NCLEX-RN Practice (Pediatrics)
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ments. Under no circumstances should re-
A. Keep restraints on at all times to prevent straints be applied to the client continuous-
unplanned extubation. ly. Documentation of assessment findings
B. Remove restraints one at a time and pro- regarding the restrained extremities must
vide range-of-motion exercises. occur much more frequently than every 72
C. Remove all restraints simultaneously and hours; however, the reason for using re-
provide play activities. straints must be justified and should be
D. Document the reason for application of stated in the medical record.
the restraints every 72 hours.
4. In making the initial assessment of a D
2-hour-old infant, which finding should Rationale:
lead the nurse to suspect a congenital heart Diminished femoral pulses could indicate
defect? coarctation of the aorta. In the normal tran-
sition period, options A and B occur during
A. Irregular respiration and heart rate the 4 to 6 hours after birth (second period
B. Gagging of reactivity). Option C is a normal finding
C. Blue feet and hands in the newborn.
D. Diminished femoral pulses
5. The nurse is preparing a health teach- B
ing program for parents of toddlers and Rationale:
preschoolers and plans to include informa- The only reliable way to prevent poisonings
tion about the prevention of accidental poi- in young children is to make the items inac-
sonings. It is most important for the nurse cessible. Teaching children not to taste any-
to include which instruction? thing but food is important but ineffective
for young children. Options C and D will not
A. Tell children that they should not taste control a child's curiosity.
anything but food.
B. Store all toxic agents and medicines in
locked cabinets.
C. Provide special play areas in the house
and restrict play in other areas.
, HESI Comprehensive NCLEX-RN Practice (Pediatrics)
Study online at https://quizlet.com/_8bgc1l
D. Punish children if they open cabinets that
contain household chemicals.
6. The nurse observes a 4-year-old boy in a C
day care setting. Which behavior should the Rationale:
nurse expect this child to exhibit? Four-year-old children are aggressive in
their behavior and enjoy telling tales. Op-
A. Throws a temper tantrum when told he tions A and D are typical toddler behaviors.
must share the toys. A preschooler's play is usually cooperative,
B. Plays by himself for most of the day. so playing alone is not typical.
C. Boasts aggressively when telling a story.
D. Cries and is fearful when separated from
his parents.
7. A nurse is preparing to end the shift and A
receives a laboratory report stating that a Rationale:
child with asthma has a theophylline lev- The therapeutic level of theophylline is 10 to
el of 15 mcg/dL. Which action should the 20 mcg/dL, so the child's level is within the
nurse take? therapeutic range. This information evalu-
ates the prescribed therapy and should be
A. Communicate the result to the oncoming communicated in the nurse's report. Based
nurse and document. on the laboratory finding, options B, C, and
B. Tell the oncoming nurse that the level is D are not indicated.
dangerously high.
C. Ask the laboratory to redo the test be-
cause the result is faulty.
D. Hold the next dose of theophylline based
on this finding.
8. The nurse is teaching the parents of a B
2-year-old child with a congenital heart de- Rationale:
fect about signs and symptoms of conges- Sudden and unexplained weight gain can
tive heart failure. Which information about indicate fluid retention and is a sign of
HESI Comprehensive NCLEX-RN Practice (Pediatrics)
ANSWERS | GRADED A+ | VERIFIED ANSWERS |
Study online at https://quizlet.com/_8bgc1l
1. Which interventions should the nurse in- B, D, E
clude in the teaching plan for the mother of Rationale:
a 6-year-old who is experiencing encopresis Encopresis is fecal incontinence, usually as
secondary to a fecal impaction? (Select all the result of recurring fecal impaction and
that apply.) an enlarged rectum caused by chronic con-
stipation. Encopresis is managed through
A.Provide a low-fiber diet. bowel retraining with mineral oil, eliminat-
B.Administer mineral oil daily. ing dairy products, and initiating a regular
C.Decrease the daily fluids. toileting routine. A high-fiber diet, not op-
D.Eliminate dairy products. tion A, and increased daily fluids, not option
E.Initiate consistent toileting routine. C, are components of care for a child with
encopresis.
2. The nurse is planning postoperative care D
for a child who has had a cleft lip repair. Rationale:
What is the most important reason to mini- Prevention of stress on the lip suture line
mize this child's crying during the recovery is essential for optimum healing and the
period? cosmetic appearance of a cleft lip repair. Al-
though crying also causes options A, B, and
A.Tear formation increases salivation. C, these conditions do not create a problem
B. This behavior increases respirations. for the child with a cleft lip repair
C. Excessive hysteria can lead to vomiting.
D. Crying stresses the suture line.
3. A 6-month-old male infant is admitted to B
the post-anesthesia care unit with elbow Rationale:
restraints in place. He has an endotra- Removing restraints one at a time is safer
cheal tube and is ventilator-dependent but than option C. The infant should have the
will be extubated soon following recovery restrained extremities assessed frequent-
from anesthesia. Which nursing interven- ly for signs of neurologic or vascular im-
tion should be included in this child's plan pairment, and range-of-motion exercises
of care? should be performed with these assess-
, HESI Comprehensive NCLEX-RN Practice (Pediatrics)
Study online at https://quizlet.com/_8bgc1l
ments. Under no circumstances should re-
A. Keep restraints on at all times to prevent straints be applied to the client continuous-
unplanned extubation. ly. Documentation of assessment findings
B. Remove restraints one at a time and pro- regarding the restrained extremities must
vide range-of-motion exercises. occur much more frequently than every 72
C. Remove all restraints simultaneously and hours; however, the reason for using re-
provide play activities. straints must be justified and should be
D. Document the reason for application of stated in the medical record.
the restraints every 72 hours.
4. In making the initial assessment of a D
2-hour-old infant, which finding should Rationale:
lead the nurse to suspect a congenital heart Diminished femoral pulses could indicate
defect? coarctation of the aorta. In the normal tran-
sition period, options A and B occur during
A. Irregular respiration and heart rate the 4 to 6 hours after birth (second period
B. Gagging of reactivity). Option C is a normal finding
C. Blue feet and hands in the newborn.
D. Diminished femoral pulses
5. The nurse is preparing a health teach- B
ing program for parents of toddlers and Rationale:
preschoolers and plans to include informa- The only reliable way to prevent poisonings
tion about the prevention of accidental poi- in young children is to make the items inac-
sonings. It is most important for the nurse cessible. Teaching children not to taste any-
to include which instruction? thing but food is important but ineffective
for young children. Options C and D will not
A. Tell children that they should not taste control a child's curiosity.
anything but food.
B. Store all toxic agents and medicines in
locked cabinets.
C. Provide special play areas in the house
and restrict play in other areas.
, HESI Comprehensive NCLEX-RN Practice (Pediatrics)
Study online at https://quizlet.com/_8bgc1l
D. Punish children if they open cabinets that
contain household chemicals.
6. The nurse observes a 4-year-old boy in a C
day care setting. Which behavior should the Rationale:
nurse expect this child to exhibit? Four-year-old children are aggressive in
their behavior and enjoy telling tales. Op-
A. Throws a temper tantrum when told he tions A and D are typical toddler behaviors.
must share the toys. A preschooler's play is usually cooperative,
B. Plays by himself for most of the day. so playing alone is not typical.
C. Boasts aggressively when telling a story.
D. Cries and is fearful when separated from
his parents.
7. A nurse is preparing to end the shift and A
receives a laboratory report stating that a Rationale:
child with asthma has a theophylline lev- The therapeutic level of theophylline is 10 to
el of 15 mcg/dL. Which action should the 20 mcg/dL, so the child's level is within the
nurse take? therapeutic range. This information evalu-
ates the prescribed therapy and should be
A. Communicate the result to the oncoming communicated in the nurse's report. Based
nurse and document. on the laboratory finding, options B, C, and
B. Tell the oncoming nurse that the level is D are not indicated.
dangerously high.
C. Ask the laboratory to redo the test be-
cause the result is faulty.
D. Hold the next dose of theophylline based
on this finding.
8. The nurse is teaching the parents of a B
2-year-old child with a congenital heart de- Rationale:
fect about signs and symptoms of conges- Sudden and unexplained weight gain can
tive heart failure. Which information about indicate fluid retention and is a sign of
