9/30/25, 3:05 PM HESI
Practice Test Assessment Performance
94%
Boom!
Correct
Incorrect Correct
During administration of a blood transfusion, a child complains of
chills, headache, and nausea. Which action should the nurse
implement?
Start another IV of dextrose solution and stay with the child.
Continue the transfusion and monitor the child's vital signs.
Stop the infusion immediately and notify the healthcare provider.
Slow the transfusion and assess for cessation of symptoms.
Rationale
The child is exhibiting signs of a reaction to the blood transfusion. The blood transfusion should be
stopped immediately and the healthcare provider notified.
,9/30/25, 3:05 PM HESI
A 15-year-old girl tells the school nurse that all of her friends have
started their periods and she feels abnormal because she has not. Which
is the best response from the nurse?
Refer the adolescent to the healthcare provider for a pregnancy screen.
Schedule a conference with her parents to recommend hormone therapy.
Explain that menarche varies and occurs between the ages of 12 and 18 years.
Suggest that she use diversions to help her not worry about delayed
menarche.
Rationale
The nurse should provide a factual and reassuring explanation that focuses on individual variations of
menarche, which can normally occur between 10 and 17 years of age.
The nurse is assessing the neurovascular status of a child in Russell
traction. Which finding should the nurse report to the healthcare
provider?
Pale bluish coloration of the toes.
Skin is warm and dry to the touch.
Toes are wiggled upon command.
Capillary refill less than 3 seconds.
Rationale
Russell skin traction is used for fractures of the femur in young children and adolescents whose growth
plates remain open and is applied to the lower leg using moleskin and elastic wrap bandages, which can
compress the peroneal nerve and arteries that supply the foot. Assessment of adequate circulation,
movement, and sensation of the toes and skin distal to the application is made to identify
compromised blood flow, so cyanosis of the toes should be reported immediately.
A hospitalized 16-year-old male refuses all visits from his classmates
because of concern about his distorted appearance. To increase the
,9/30/25, 3:05 PM HESI
client's social interaction, what intervention is best for the nurse to
initiate?
Encourage the client to use a hand-held video game that is popular with all his
friends.
Arrange for a home-bound teacher to assist with school work.
Arrange for an Internet connection in the client's room for email
communication.
Encourage the client's mother to arrange a surprise get together in the
cafeteria.
Rationale
Body image and peer acceptance are key concerns for the adolescent. Communication via email allows
for social interaction without face-to-face contact, thus protecting the client's self-image while also
promoting social interaction.
The mother of a 2-year-old boy consults the nurse about her son's
increased temper tantrums. The mother states, "Yesterday he threw a fit
in the grocery store, and I did not know what to do. I was so
embarrassed. What can I do if this occurs again?" Which
recommendation is best for the nurse to provide this mother?
Paddle him gently as soon as the behavior is initiated.
Immediately put him in "time-out."
Quietly remind him that others are watching him.
Walk a few feet away from him and ignore the behavior.
Rationale
The best approach for a toddler's inappropriate behavior is to ignore the attention-seeking behavior. The
parent should remain close, within view of the child and quickly accessible, but should avoid reinforcing
the behavior in any way. Tantrums can sometimes be avoided by talking to the child before the situation
occurs.
, 9/30/25, 3:05 PM HESI
The mother of a preschool-aged child asks the nurse if it is all right to
administer bismuth subsalicylate to her son when he has a "tummy
ache." After reminding the mother to check the label of all over-the-
counter drugs for the presence of aspirin, which instruction should the
nurse include when replying to this mother's question?
If the child's tongue darkens, discontinue the bismuth subsalicylate
immediately.
Do not give if the child has chickenpox, the flu, or any other viral illness.
Avoid the use of bismuth subsalicylate until the child is at least 16 years of
age.
Bismuth subsalicylate may cause a rebound hyperacidity, worsening the
"tummy ache."
Rationale
Families need to be aware that salicylates, the alleged offending ingredient in aspirin, are contained in
other products (e.g., bismuth subsalicylate). They should refrain from administering any products
without first checking the label for “hidden” salicylates to avoid the possible development of Reye
syndrome, which is potentially fatal. Parents should consult with their child's pediatrician prior to giving
any new medications.
When evaluating the effectiveness of interventions to improve the
nutritional status of an infant with gastroesophageal reflux, which
intervention is most important for the nurse to implement?
Record weight daily.
Assess for signs of anemia.
Document sleeping patterns.
Teach parenting skills.
Rationale
The most definitive measure of improved nutrition in an infant is obtaining the infant's daily weight at
the same time and ideally using the same scale with the infant naked.
Practice Test Assessment Performance
94%
Boom!
Correct
Incorrect Correct
During administration of a blood transfusion, a child complains of
chills, headache, and nausea. Which action should the nurse
implement?
Start another IV of dextrose solution and stay with the child.
Continue the transfusion and monitor the child's vital signs.
Stop the infusion immediately and notify the healthcare provider.
Slow the transfusion and assess for cessation of symptoms.
Rationale
The child is exhibiting signs of a reaction to the blood transfusion. The blood transfusion should be
stopped immediately and the healthcare provider notified.
,9/30/25, 3:05 PM HESI
A 15-year-old girl tells the school nurse that all of her friends have
started their periods and she feels abnormal because she has not. Which
is the best response from the nurse?
Refer the adolescent to the healthcare provider for a pregnancy screen.
Schedule a conference with her parents to recommend hormone therapy.
Explain that menarche varies and occurs between the ages of 12 and 18 years.
Suggest that she use diversions to help her not worry about delayed
menarche.
Rationale
The nurse should provide a factual and reassuring explanation that focuses on individual variations of
menarche, which can normally occur between 10 and 17 years of age.
The nurse is assessing the neurovascular status of a child in Russell
traction. Which finding should the nurse report to the healthcare
provider?
Pale bluish coloration of the toes.
Skin is warm and dry to the touch.
Toes are wiggled upon command.
Capillary refill less than 3 seconds.
Rationale
Russell skin traction is used for fractures of the femur in young children and adolescents whose growth
plates remain open and is applied to the lower leg using moleskin and elastic wrap bandages, which can
compress the peroneal nerve and arteries that supply the foot. Assessment of adequate circulation,
movement, and sensation of the toes and skin distal to the application is made to identify
compromised blood flow, so cyanosis of the toes should be reported immediately.
A hospitalized 16-year-old male refuses all visits from his classmates
because of concern about his distorted appearance. To increase the
,9/30/25, 3:05 PM HESI
client's social interaction, what intervention is best for the nurse to
initiate?
Encourage the client to use a hand-held video game that is popular with all his
friends.
Arrange for a home-bound teacher to assist with school work.
Arrange for an Internet connection in the client's room for email
communication.
Encourage the client's mother to arrange a surprise get together in the
cafeteria.
Rationale
Body image and peer acceptance are key concerns for the adolescent. Communication via email allows
for social interaction without face-to-face contact, thus protecting the client's self-image while also
promoting social interaction.
The mother of a 2-year-old boy consults the nurse about her son's
increased temper tantrums. The mother states, "Yesterday he threw a fit
in the grocery store, and I did not know what to do. I was so
embarrassed. What can I do if this occurs again?" Which
recommendation is best for the nurse to provide this mother?
Paddle him gently as soon as the behavior is initiated.
Immediately put him in "time-out."
Quietly remind him that others are watching him.
Walk a few feet away from him and ignore the behavior.
Rationale
The best approach for a toddler's inappropriate behavior is to ignore the attention-seeking behavior. The
parent should remain close, within view of the child and quickly accessible, but should avoid reinforcing
the behavior in any way. Tantrums can sometimes be avoided by talking to the child before the situation
occurs.
, 9/30/25, 3:05 PM HESI
The mother of a preschool-aged child asks the nurse if it is all right to
administer bismuth subsalicylate to her son when he has a "tummy
ache." After reminding the mother to check the label of all over-the-
counter drugs for the presence of aspirin, which instruction should the
nurse include when replying to this mother's question?
If the child's tongue darkens, discontinue the bismuth subsalicylate
immediately.
Do not give if the child has chickenpox, the flu, or any other viral illness.
Avoid the use of bismuth subsalicylate until the child is at least 16 years of
age.
Bismuth subsalicylate may cause a rebound hyperacidity, worsening the
"tummy ache."
Rationale
Families need to be aware that salicylates, the alleged offending ingredient in aspirin, are contained in
other products (e.g., bismuth subsalicylate). They should refrain from administering any products
without first checking the label for “hidden” salicylates to avoid the possible development of Reye
syndrome, which is potentially fatal. Parents should consult with their child's pediatrician prior to giving
any new medications.
When evaluating the effectiveness of interventions to improve the
nutritional status of an infant with gastroesophageal reflux, which
intervention is most important for the nurse to implement?
Record weight daily.
Assess for signs of anemia.
Document sleeping patterns.
Teach parenting skills.
Rationale
The most definitive measure of improved nutrition in an infant is obtaining the infant's daily weight at
the same time and ideally using the same scale with the infant naked.
