HESI PN NURSING CARE OF CHILDREN PROCTORED EXAM
42 Latest Exam Sets
4000 Plus Question With Correct Answers
Complete Updated Document For Exam Preparation
HESI
Test Preparation
New 2023 Edition
, HESI PN NURSING CARE OF CHILDREN PROCTORED EXAM
VERSION 1
A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following
manifestations should alert the nurse to a possible hemolytic transfusion reaction?
a. Laryngeal edema
b. Flank pain
c. Distended neck veins
d. Muscular weakness
Answer- b. Flank pain. The nurse should recognize that flank pain is caused by the breakdown of RBCs
and is an indication of a hemolytic reaction to the blood transfusion.
A- Laryngeal edema is an indication of an allergic reaction to the blood transfusion.
C- Distended neck veins are an indication of circulatory overload, which is a
complication of a blood transfusion. D- Muscle weakness is an indication of an
electrolyte disturbance, which is a complication of a blood transfusion.
A community health nurse is assessing an 18-month-old toddler in a community day care. Which of
the following findings should the nurse identify as a potential indication of physical neglect?
a. Resists having an axillary temperature taken
b. Exhibits withdrawal behaviors when her parent leaves
c. Has multiple bruises on her knees
d. Poor personal hygiene
Answer- d. Poor personal hygiene. Poor personal hygiene in a toddler is a potential indication of physical
neglect. Because toddlers are still dependent on their parents for help with hygiene needs, poor personal
hygiene indicates a lack of supervision.
A- The toddler has begun to develop a sense of body image and boundaries and can be resistant to
intrusive assessments such as assessing the mouth or ears, or taking an axillary temperature. Therefore,
this finding is not an indication of physical neglect.
B- Separation anxiety is an expected finding for a toddler. The child of this age can become fearful and
exhibit regressive behaviors when left alone with strangers and separated from her parents; therefore,
this finding is not an indication of physical neglect.
C- The 18-month-old toddler has accomplished the gross motor skills of standing and walking and has
begun to try to run but falls easily and can have bruises on her knees. Therefore, this finding is not an
,indication of physical neglect.
A nurse is caring for a school-age child who is receiving chemotherapy and is severely
immunocompromised. Which of the following actions should the nurse take?
a. Use surgical asepsis when providing routine care for the child.
b. Administer the measles, mumps, rubella (MMR) vaccine to the child.
c. Screen the child's visitors for indications of infection.
d. Infuse packed RBCs.
Answer- c. Screen the child's visitors for indications of infection. The child who is severely
immunocompromised is unable to adequately respond to infectious organisms resulting in the potential
for overwhelming infection; therefore, the nurse should screen the child's visitors for indications of
infection.
A- It is not necessary for the nurse to use surgical asepsis when providing direct care. Strict hand
washing and medical asepsis are recommended to prevent the spread of infection.
B- It is contraindicated for a child who is severely immunocompromised to receive the MMR vaccine
because it is a live virus vaccine and the child may not be able to build adequate antibodies to prevent
infection with the organism.
D- A child who is immunocompromised as a result of chemotherapy will have a decreased neutrophil
count. The nurse should plan to infuse packed RBCs to the child who is anemic. However, packed
RBCs will not increase the child’s neutrophil count.
A nurse is teaching a school-age child who has a severe allergy to bee venom and his parent about
epinephrine. Which of the following instructions should the nurse include in the teaching?
a. Use a second dose if the first dose of epinephrine does not completely reverse the symptoms.
b. Store unused epinephrine syringes in the refrigerator.
c. Shake the epinephrine syringe prior to use to dissolve the precipitate.
d. Administer the medication subcutaneously in the back of the arm.
Answer- a. Use a second dose if the first dose of epinephrine does not completely reverse the symptoms.
A biphasic response, in which the child will appear to recover and then experience a recurrence of
symptoms, is possible with some allergic reactions. The nurse should instruct the parent and child to use
a second dose if the first dose does not resolve all the symptoms.
B- The nurse should instruct the parent and child to store epinephrine in a dark area at room
temperature. Refrigeration of an epinephrine syringe can result in failure of the injection mechanism to
work.
C- The nurse should instruct the child and his parent that the formation of precipitate or a brown
coloration to the solution is an indication that the medication should be replaced and not used.
D- The nurse should instruct the child and his parent to inject the medication intramuscularly into the
anterolateral aspect of the middle thigh .
,A nurse is assessing a school-age child who has appendicitis with possible perforation. The nurse
should identify which of the following as a manifestation of peritonitis?
a. Hyperactive bowel sounds
b. Abdominal distention
c. Bradycardia
d. Polyuria
Answer- b. Abdominal distention. The nurse should recognize that abdominal distention is a
manifestation of peritonitis. Peritonitis is an inflammation of the lining of the abdominal wall. This
inflammation in the abdomen, along with the ileus that develops, causes abdominal distention.
A- Hypoactive bowel sounds are a manifestation of peritonitis. The peritoneal inflammation caused by the
feces and bacteria released from the perforated appendix results in the development of an ileus, and a
decrease in bowel motility.
C- Tachycardia is a manifestation of peritonitis resulting from infection and fluid shifts within the
abdomen, which causes hypovolemia. D- Polyuria occurs with an elevated glucose level and is
not a manifestation of peritonitis.
42 Latest Exam Sets
4000 Plus Question With Correct Answers
Complete Updated Document For Exam Preparation
HESI
Test Preparation
New 2023 Edition
, HESI PN NURSING CARE OF CHILDREN PROCTORED EXAM
VERSION 1
A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following
manifestations should alert the nurse to a possible hemolytic transfusion reaction?
a. Laryngeal edema
b. Flank pain
c. Distended neck veins
d. Muscular weakness
Answer- b. Flank pain. The nurse should recognize that flank pain is caused by the breakdown of RBCs
and is an indication of a hemolytic reaction to the blood transfusion.
A- Laryngeal edema is an indication of an allergic reaction to the blood transfusion.
C- Distended neck veins are an indication of circulatory overload, which is a
complication of a blood transfusion. D- Muscle weakness is an indication of an
electrolyte disturbance, which is a complication of a blood transfusion.
A community health nurse is assessing an 18-month-old toddler in a community day care. Which of
the following findings should the nurse identify as a potential indication of physical neglect?
a. Resists having an axillary temperature taken
b. Exhibits withdrawal behaviors when her parent leaves
c. Has multiple bruises on her knees
d. Poor personal hygiene
Answer- d. Poor personal hygiene. Poor personal hygiene in a toddler is a potential indication of physical
neglect. Because toddlers are still dependent on their parents for help with hygiene needs, poor personal
hygiene indicates a lack of supervision.
A- The toddler has begun to develop a sense of body image and boundaries and can be resistant to
intrusive assessments such as assessing the mouth or ears, or taking an axillary temperature. Therefore,
this finding is not an indication of physical neglect.
B- Separation anxiety is an expected finding for a toddler. The child of this age can become fearful and
exhibit regressive behaviors when left alone with strangers and separated from her parents; therefore,
this finding is not an indication of physical neglect.
C- The 18-month-old toddler has accomplished the gross motor skills of standing and walking and has
begun to try to run but falls easily and can have bruises on her knees. Therefore, this finding is not an
,indication of physical neglect.
A nurse is caring for a school-age child who is receiving chemotherapy and is severely
immunocompromised. Which of the following actions should the nurse take?
a. Use surgical asepsis when providing routine care for the child.
b. Administer the measles, mumps, rubella (MMR) vaccine to the child.
c. Screen the child's visitors for indications of infection.
d. Infuse packed RBCs.
Answer- c. Screen the child's visitors for indications of infection. The child who is severely
immunocompromised is unable to adequately respond to infectious organisms resulting in the potential
for overwhelming infection; therefore, the nurse should screen the child's visitors for indications of
infection.
A- It is not necessary for the nurse to use surgical asepsis when providing direct care. Strict hand
washing and medical asepsis are recommended to prevent the spread of infection.
B- It is contraindicated for a child who is severely immunocompromised to receive the MMR vaccine
because it is a live virus vaccine and the child may not be able to build adequate antibodies to prevent
infection with the organism.
D- A child who is immunocompromised as a result of chemotherapy will have a decreased neutrophil
count. The nurse should plan to infuse packed RBCs to the child who is anemic. However, packed
RBCs will not increase the child’s neutrophil count.
A nurse is teaching a school-age child who has a severe allergy to bee venom and his parent about
epinephrine. Which of the following instructions should the nurse include in the teaching?
a. Use a second dose if the first dose of epinephrine does not completely reverse the symptoms.
b. Store unused epinephrine syringes in the refrigerator.
c. Shake the epinephrine syringe prior to use to dissolve the precipitate.
d. Administer the medication subcutaneously in the back of the arm.
Answer- a. Use a second dose if the first dose of epinephrine does not completely reverse the symptoms.
A biphasic response, in which the child will appear to recover and then experience a recurrence of
symptoms, is possible with some allergic reactions. The nurse should instruct the parent and child to use
a second dose if the first dose does not resolve all the symptoms.
B- The nurse should instruct the parent and child to store epinephrine in a dark area at room
temperature. Refrigeration of an epinephrine syringe can result in failure of the injection mechanism to
work.
C- The nurse should instruct the child and his parent that the formation of precipitate or a brown
coloration to the solution is an indication that the medication should be replaced and not used.
D- The nurse should instruct the child and his parent to inject the medication intramuscularly into the
anterolateral aspect of the middle thigh .
,A nurse is assessing a school-age child who has appendicitis with possible perforation. The nurse
should identify which of the following as a manifestation of peritonitis?
a. Hyperactive bowel sounds
b. Abdominal distention
c. Bradycardia
d. Polyuria
Answer- b. Abdominal distention. The nurse should recognize that abdominal distention is a
manifestation of peritonitis. Peritonitis is an inflammation of the lining of the abdominal wall. This
inflammation in the abdomen, along with the ileus that develops, causes abdominal distention.
A- Hypoactive bowel sounds are a manifestation of peritonitis. The peritoneal inflammation caused by the
feces and bacteria released from the perforated appendix results in the development of an ileus, and a
decrease in bowel motility.
C- Tachycardia is a manifestation of peritonitis resulting from infection and fluid shifts within the
abdomen, which causes hypovolemia. D- Polyuria occurs with an elevated glucose level and is
not a manifestation of peritonitis.
