HESI RN PEDIATRICS EXAM 55
ANSWERS Questions and Answers
(Verified Answers)
Question 1
The nurse is caring for a 3-year-old child who is 2 hours
post-op from a cardiac catheterization via the right
femoral artery. Which assessment finding is an indication
of arterial obstruction?
A. Blood pressure trend is downward and pulse is rapid and
irregular.
B. Right foot is cool to the touch and appears pale
and blanched.
C. Pulse distal to the femoral artery is weaker on the left foot
than the right foot.
D. The pressure dressing at the right femoral area is moist
and oozing blood.
Correct Answer: B. Right foot is cool to the touch and
appears pale and blanched.
,Rationale: Signs of arterial occlusion distal to a catheterization
site include loss of pulse, pallor/blanching, cool extremity
temperature, delayed capillary refill, and pain (the "Ps" of
ischemia).
Question 2
Following a motor vehicle collision, a 3-year-old girl has a
spica cast applied. Which toy is best for the nurse to
provide for this 3-year-old child?
A. Duck that squeaks.
B. Fashion doll and clothes.
C. Set of cloth and hand puppets.
D. Hand-held video game.
Correct Answer: C. Set of cloth and hand puppets.
Rationale: A 3-year-old (preschooler) benefits from imaginative,
dramatic play that can be performed while immobilized in a spica
cast without dropping small parts inside the cast or requiring
complex fine motor control.
Question 3
An infant with Tetralogy of Fallot becomes acutely
cyanotic and hyperpneic. Which action should the nurse
implement first?
A. Administer morphine sulfate.
, B. Start IV fluids.
C. Place the infant in a knee-chest position.
D. Provide 100% oxygen by face mask.
Correct Answer: C. Place the infant in a knee-chest
position.
Rationale: Placing the child in a knee-chest (squatting) position
increases systemic vascular resistance (SVR), which decreases
the right-to-left shunt across the VSD and directs more
unoxygenated blood into the pulmonary arteries to improve
oxygenation during a hypercyanotic ("Tet") spell.
Question 4
A child admitted with diabetic ketoacidosis (DKA) is
demonstrating Kussmaul respirations. The nurse
determines that the increased respiratory rate is a
compensatory mechanism for which acid-base alteration?
A. Metabolic alkalosis.
B. Respiratory acidosis.
C. Respiratory alkalosis.
D. Metabolic acidosis.
Correct Answer: D. Metabolic acidosis.
, Rationale: Kussmaul respirations are deep, rapid breaths that
serve as a respiratory compensation mechanism to blow off
excess carbon dioxide (CO 2) and raise blood pH during severe
metabolic acidosis.
Question 5
A 7-year-old is admitted to the hospital with persistent
vomiting, and a nasogastric (NG) tube attached to low
intermittent suction is applied. Which finding is most
important for the nurse to report to the healthcare
provider?
A. Gastric output of 100 mL in the last 8 hours.
B. Shift intake of 640 mL IV fluids plus 30 mL PO ice chips.
C. Serum potassium of 3.0 mEq/L.
D. Serum pH of 7.45.
Correct Answer: C. Serum potassium of 3.0 mEq/L.
Rationale: Persistent vomiting and NG suction lead to severe loss
of gastric fluids, resulting in hypokalemia (normal range: 3.5–5.0
mEq/L). Hypokalemia poses a significant risk for cardiac
dysrhythmias and muscle weakness.
Question 6
ANSWERS Questions and Answers
(Verified Answers)
Question 1
The nurse is caring for a 3-year-old child who is 2 hours
post-op from a cardiac catheterization via the right
femoral artery. Which assessment finding is an indication
of arterial obstruction?
A. Blood pressure trend is downward and pulse is rapid and
irregular.
B. Right foot is cool to the touch and appears pale
and blanched.
C. Pulse distal to the femoral artery is weaker on the left foot
than the right foot.
D. The pressure dressing at the right femoral area is moist
and oozing blood.
Correct Answer: B. Right foot is cool to the touch and
appears pale and blanched.
,Rationale: Signs of arterial occlusion distal to a catheterization
site include loss of pulse, pallor/blanching, cool extremity
temperature, delayed capillary refill, and pain (the "Ps" of
ischemia).
Question 2
Following a motor vehicle collision, a 3-year-old girl has a
spica cast applied. Which toy is best for the nurse to
provide for this 3-year-old child?
A. Duck that squeaks.
B. Fashion doll and clothes.
C. Set of cloth and hand puppets.
D. Hand-held video game.
Correct Answer: C. Set of cloth and hand puppets.
Rationale: A 3-year-old (preschooler) benefits from imaginative,
dramatic play that can be performed while immobilized in a spica
cast without dropping small parts inside the cast or requiring
complex fine motor control.
Question 3
An infant with Tetralogy of Fallot becomes acutely
cyanotic and hyperpneic. Which action should the nurse
implement first?
A. Administer morphine sulfate.
, B. Start IV fluids.
C. Place the infant in a knee-chest position.
D. Provide 100% oxygen by face mask.
Correct Answer: C. Place the infant in a knee-chest
position.
Rationale: Placing the child in a knee-chest (squatting) position
increases systemic vascular resistance (SVR), which decreases
the right-to-left shunt across the VSD and directs more
unoxygenated blood into the pulmonary arteries to improve
oxygenation during a hypercyanotic ("Tet") spell.
Question 4
A child admitted with diabetic ketoacidosis (DKA) is
demonstrating Kussmaul respirations. The nurse
determines that the increased respiratory rate is a
compensatory mechanism for which acid-base alteration?
A. Metabolic alkalosis.
B. Respiratory acidosis.
C. Respiratory alkalosis.
D. Metabolic acidosis.
Correct Answer: D. Metabolic acidosis.
, Rationale: Kussmaul respirations are deep, rapid breaths that
serve as a respiratory compensation mechanism to blow off
excess carbon dioxide (CO 2) and raise blood pH during severe
metabolic acidosis.
Question 5
A 7-year-old is admitted to the hospital with persistent
vomiting, and a nasogastric (NG) tube attached to low
intermittent suction is applied. Which finding is most
important for the nurse to report to the healthcare
provider?
A. Gastric output of 100 mL in the last 8 hours.
B. Shift intake of 640 mL IV fluids plus 30 mL PO ice chips.
C. Serum potassium of 3.0 mEq/L.
D. Serum pH of 7.45.
Correct Answer: C. Serum potassium of 3.0 mEq/L.
Rationale: Persistent vomiting and NG suction lead to severe loss
of gastric fluids, resulting in hypokalemia (normal range: 3.5–5.0
mEq/L). Hypokalemia poses a significant risk for cardiac
dysrhythmias and muscle weakness.
Question 6
