2025|26 HESI PEDIATRICS RN EXAM
QUESTIONS AND ANSWERS
(VERIFIED AND WELL DETAILED
ANSWERS
QUESTIONS INDICATION[###]
EXPLANATION[**}
###1. The nurse is giving preoperative instructions to a 14-year old
female client who is scheduled for surgery to correct a spinal curvature.
Which statement by the client best demonstrates that learning has taken
place?
A. I will read all the literature you gave me before surgery.
B. I have had surgery before when I broke my wrist in a bike accident, so I
know what to expect.
C. All the things people have told me will help me take care of my back.
D. I understand that I will be in a body cast and I will show you how you
taught me to turn. - CORRECT ANSWER- D. I understand that I will be in a
body cast and I will show you how you taught me to turn.
https://www.stuvia.com/user/Mboffin
,**EXPERT EXPLANATION**
Outcome of learning is best demonstrated when the client not only
verbalizes an understanding, but also can provide a return
demonstration. A 14-year old may or may not follow through with reading
material and there is no way of measuring that way of learning. Have a
previous surgery may help the client understand the surgical process, but
wrist surgery is very different from spinal surgery and emergency surgery
is different than elective surgery. In (C), the client may be saying what the
nurse wants to hear, without expressing any real understanding of what to
do after surgery.
###2. To take the vital signs of a 4-month old child, which order will give
the most accurate results?
A. Respiratory rate, heart rate, then rectal temperature
https://www.stuvia.com/user/Mboffin
,B. Heart rate, rectal temperature, then respiratory rate.
C. Rectal temperature, heart rate, then respiratory rate
D. Rectal temperature, respiratory rate, then heart rate – CORRECT
ANSWER-
A. Respiratory rate, heart rate, then rectal temperature
**EXPERT EXPLANATION**
The respiratory rate should be taken first in infants, since touching them
or performing unpleasant procedures usually makes them cry, elevating
the heart rate and making respirations difficult to count. Rectal
temperature is the most invasive procedure, and is not likely to
precipitate crying, so should be done last.
###3. During routine screening at a school clinic, an otoscope
examination of a child's ear reveals a tympanic membrane that is pearly
gray, slightly bulging, and not movable. What action should the nurse
take next?
A. No action required, as this is an expected finding for a school-aged child
B. Ask the child if he/she has had a cold, runny nose, or any ear pain lately.
C. Send a note home advising the parents to have the child evaluated by a
healthcare provider as soon as possible.
d. Call the parents and have them take the child home from school for the
rest of the day. - CORRECT ANSWER- B. Ask the child if he/she has had a
cold, runny nose, or any ear pain lately.
**EXPERT EXPLANATION**
More information is needed to interpret these findings. The tympanic
membrane is normally pearly gray, not bulging, and moves when the
client blows against resistance or a small puff of air is blown into the ear
canal. Since this child's findings are not completely normal, further
assessment of history and related signs and symptoms is indicated for
accurate interpretation of the findings. (A), (C), and
(D) are inappropriate actions based on the data obtained from the
https://www.stuvia.com/user/Mboffin
, otoscope examination.
https://www.stuvia.com/user/Mboffin
QUESTIONS AND ANSWERS
(VERIFIED AND WELL DETAILED
ANSWERS
QUESTIONS INDICATION[###]
EXPLANATION[**}
###1. The nurse is giving preoperative instructions to a 14-year old
female client who is scheduled for surgery to correct a spinal curvature.
Which statement by the client best demonstrates that learning has taken
place?
A. I will read all the literature you gave me before surgery.
B. I have had surgery before when I broke my wrist in a bike accident, so I
know what to expect.
C. All the things people have told me will help me take care of my back.
D. I understand that I will be in a body cast and I will show you how you
taught me to turn. - CORRECT ANSWER- D. I understand that I will be in a
body cast and I will show you how you taught me to turn.
https://www.stuvia.com/user/Mboffin
,**EXPERT EXPLANATION**
Outcome of learning is best demonstrated when the client not only
verbalizes an understanding, but also can provide a return
demonstration. A 14-year old may or may not follow through with reading
material and there is no way of measuring that way of learning. Have a
previous surgery may help the client understand the surgical process, but
wrist surgery is very different from spinal surgery and emergency surgery
is different than elective surgery. In (C), the client may be saying what the
nurse wants to hear, without expressing any real understanding of what to
do after surgery.
###2. To take the vital signs of a 4-month old child, which order will give
the most accurate results?
A. Respiratory rate, heart rate, then rectal temperature
https://www.stuvia.com/user/Mboffin
,B. Heart rate, rectal temperature, then respiratory rate.
C. Rectal temperature, heart rate, then respiratory rate
D. Rectal temperature, respiratory rate, then heart rate – CORRECT
ANSWER-
A. Respiratory rate, heart rate, then rectal temperature
**EXPERT EXPLANATION**
The respiratory rate should be taken first in infants, since touching them
or performing unpleasant procedures usually makes them cry, elevating
the heart rate and making respirations difficult to count. Rectal
temperature is the most invasive procedure, and is not likely to
precipitate crying, so should be done last.
###3. During routine screening at a school clinic, an otoscope
examination of a child's ear reveals a tympanic membrane that is pearly
gray, slightly bulging, and not movable. What action should the nurse
take next?
A. No action required, as this is an expected finding for a school-aged child
B. Ask the child if he/she has had a cold, runny nose, or any ear pain lately.
C. Send a note home advising the parents to have the child evaluated by a
healthcare provider as soon as possible.
d. Call the parents and have them take the child home from school for the
rest of the day. - CORRECT ANSWER- B. Ask the child if he/she has had a
cold, runny nose, or any ear pain lately.
**EXPERT EXPLANATION**
More information is needed to interpret these findings. The tympanic
membrane is normally pearly gray, not bulging, and moves when the
client blows against resistance or a small puff of air is blown into the ear
canal. Since this child's findings are not completely normal, further
assessment of history and related signs and symptoms is indicated for
accurate interpretation of the findings. (A), (C), and
(D) are inappropriate actions based on the data obtained from the
https://www.stuvia.com/user/Mboffin
, otoscope examination.
https://www.stuvia.com/user/Mboffin
