Evolve HESI peds Practice Questions
A 12-month-old boy is admitted with a respiratory infection and possible pneumonia. He is
placed in a mist tent with oxygen. Which nursing intervention has the greatest priority for this
infant?
Give small, frequent feedings of fluids.
Accurately chart observations regarding breath sounds.
Have a bulb syringe readily available to remove secretions.
Encourage older siblings to visit. - ANS - Have a bulb syringe readily available to remove
secretions.
A patent airway has the highest priority. Humidification will liquefy the nasal secretions thereby
increasing the amount of secretions and making (C) the highest priority. (A) maintains hydration
and prevent tiring, but an open airway has a higher priority! (B) is important for evaluation of
therapy. When asked "priority" questions, REMEMBER MASLOW! Physical needs usually have
a higher priority than psychosocial needs (D) and an open airway is the highest physiological
need!
A 14-year-old female client tells the nurse that she is concerned about the acne she has
recently developed. Which recommendation should the nurse provide?
Remove all blackheads and follow with an alcohol scrub.
Use medicated cosmetics only to help hide the blemishes.
Wash the hair and skin frequently with soap and hot water.
Encourage her to see a dermatologist as soon as possible. - ANS - Wash the hair and skin
frequently with soap and hot water.
Washing the hair and skin with soap and hot water (C) removes oil and debris from the skin and
helps prevent and treat acne. Oily skin is especially bothersome during adolescence when
hormones cause enlargement of sebaceous glands and increased glandular secretions which
predispose the teenager to acne. (A) is contraindicated. Cosmetics ("medicated" or not) should
be used sparingly to avoid further blocking sebaceous gland ducts (B). (D) might be indicated at
a later time, if healthcare recommendations are not successful.
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 response is best for the nurse provide?
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. - ANS - Explain
that menarche varies and occurs between the ages of 12 and 18 years.
,The nurse should provide a factual and reassuring explanation that focuses on individual
variations of menarche, which can normally occur between 12 and 18 years of age (C). (A) does
not address the adolescent's concern and is judgmental. Menarche is influenced by hereditary,
general health, and nutritional status, so (B) is not indicated. (D) dismisses the adolescent's
concerns and does not offer factual information.
A 16-year-old is brought to the Emergency Center with a crushed leg after falling off a horse.
The adolescent's last tetanus toxoid booster was received eight years ago. What action should
the nurse take?
Dispense a tetanus antitoxin.
Prepare human tetanus immune globulin.
Administer tetanus toxoid booster.
Delay the tetanus toxoid booster until due. - ANS - Administer tetanus toxoid booster.
After the completion of the initial tetanus immunization schedule, the recommended booster for
an adolescent or adult is every ten years or less if a traumatic injury occurs that is contaminated
by dirt, feces, soil, or saliva, such as puncture or crushing injuries, avulsions, wounds from
missiles, burns, or frostbite. The adolescent's injury is considered a contaminated wound
requiring prophylactic therapy, so the tetanus toxoid booster should be administered (C). (A, B,
and D) are not indicated.
A 17-year-old male student reports to the school clinic one morning for a scheduled health
exam. He tells the nurse that he just finished football practice and is on his way to class. The
nurse assesses his vital signs: temperature 100° F, pulse 80, respirations 20, and blood
pressure 122/82. What is the best action for the nurse to take?
Tell the student to proceed directly to his regularly scheduled class.
Call the parent and suggest re-taking the student's temperature at home.
Give the student a glass of cool fluids, then retake his temperature.
Send the student to class, but re-verify his temperature after lunch. - ANS - Tell the student to
proceed directly to his regularly scheduled class.
This student has just completed football practice, and increased muscle activity increases body
heat production. A temperature of 100° F is normal for this student at this time. The student
should attend class (A) since no further nursing action is required. (B) would alarm the parents
unnecessarily. (C) would provide a false reading of body temperature. (D) is unnecessary since
these findings are within normal limits.
A 2-year-old child recently diagnosed with hemophilia A is discharged home. What information
should the nurse include in a teaching plan about home care?
Minimize interactive play with other children to lessen chances for injury.
Give low-dose children's chewable aspirin in orange flavor for joint discomfort.
Use a firm and dry toothbrush to clean teeth at least twice per day.
Apply pressure and ice for bleeding while elevating and resting the extremity. - ANS - Apply
pressure and ice for bleeding while elevating and resting the extremity.
, Hemophilia, a blood disorder, causes joint bleeding which is treated with rest, ice, compression,
and elevation (RICE) (D). (A, B, and C) are inaccurate.
A 2-year-old child with Down syndrome is brought to the clinic for his regular physical
examination. The nurse knows which problem is frequently associated with Down syndrome?
Congenital heart disease.
Fragile X chromosome.
Trisomy 13.
Pyloric stenosis. - ANS - Congenital heart disease.
Congenital heart disease (A) is the most common associated defect in children with Down
syndrome. (C) might have seemed possible since Down syndrome is a trisomal chromosomal
abnormality of chromosome 21. (B) is a sex-linked abnormality also causing mental retardation.
(D) is not associated with Down syndrome.
A 2-year-old child with gastro-esophageal reflux has developed a fear of eating. What
instruction should the nurse include in the parents' teaching plan?
Invite other children home to share meals.
Accept that he will eat when he is hungry.
Reward the child with a nap after eating.
Consistently follow a set mealtime routine. - ANS - Consistently follow a set mealtime routine.
A 2-year-old child is comforted by consistency (D). (A) is contraindicated because two-year-olds
may participate in parallel activities with other children but are too young to feel comfort and
support by the presence of other children when anxious or afraid. (B) may or may not be true
and does not address the child's fears. The child with reflux should remain upright at least two
hours after eating (C) to reduce symptoms.
A 3-month-old infant develops oral thrush. Which pharmacologic agent should the nurse plan to
administer for treatment of this disorder?
Nystatin (Mycostatin).
Nitrofurantoin (Macrodantin).
Norfloxacin (Noroxin).
Neomycin sulfate (Mycifradin). - ANS - Nystatin (Mycostatin).
Nystatin (Mycostatin) (A) is an antifungal drug that is effective in treating thrush, an oral fungal
infection. (B, C, and D) are not indicated for the treatment of oral thrush.
A 3-week-old newborn is brought to the clinic for follow-up after a home birth. The mother
reports that her child bottle feeds for 5 minutes only and then falls asleep. The nurse
auscultates a loud murmur characteristic of a ventricular septal defect (VSD), and finds the
newborn is acyanotic with a respiratory rate of 64 breaths per minute. What instruction should
A 12-month-old boy is admitted with a respiratory infection and possible pneumonia. He is
placed in a mist tent with oxygen. Which nursing intervention has the greatest priority for this
infant?
Give small, frequent feedings of fluids.
Accurately chart observations regarding breath sounds.
Have a bulb syringe readily available to remove secretions.
Encourage older siblings to visit. - ANS - Have a bulb syringe readily available to remove
secretions.
A patent airway has the highest priority. Humidification will liquefy the nasal secretions thereby
increasing the amount of secretions and making (C) the highest priority. (A) maintains hydration
and prevent tiring, but an open airway has a higher priority! (B) is important for evaluation of
therapy. When asked "priority" questions, REMEMBER MASLOW! Physical needs usually have
a higher priority than psychosocial needs (D) and an open airway is the highest physiological
need!
A 14-year-old female client tells the nurse that she is concerned about the acne she has
recently developed. Which recommendation should the nurse provide?
Remove all blackheads and follow with an alcohol scrub.
Use medicated cosmetics only to help hide the blemishes.
Wash the hair and skin frequently with soap and hot water.
Encourage her to see a dermatologist as soon as possible. - ANS - Wash the hair and skin
frequently with soap and hot water.
Washing the hair and skin with soap and hot water (C) removes oil and debris from the skin and
helps prevent and treat acne. Oily skin is especially bothersome during adolescence when
hormones cause enlargement of sebaceous glands and increased glandular secretions which
predispose the teenager to acne. (A) is contraindicated. Cosmetics ("medicated" or not) should
be used sparingly to avoid further blocking sebaceous gland ducts (B). (D) might be indicated at
a later time, if healthcare recommendations are not successful.
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 response is best for the nurse provide?
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. - ANS - Explain
that menarche varies and occurs between the ages of 12 and 18 years.
,The nurse should provide a factual and reassuring explanation that focuses on individual
variations of menarche, which can normally occur between 12 and 18 years of age (C). (A) does
not address the adolescent's concern and is judgmental. Menarche is influenced by hereditary,
general health, and nutritional status, so (B) is not indicated. (D) dismisses the adolescent's
concerns and does not offer factual information.
A 16-year-old is brought to the Emergency Center with a crushed leg after falling off a horse.
The adolescent's last tetanus toxoid booster was received eight years ago. What action should
the nurse take?
Dispense a tetanus antitoxin.
Prepare human tetanus immune globulin.
Administer tetanus toxoid booster.
Delay the tetanus toxoid booster until due. - ANS - Administer tetanus toxoid booster.
After the completion of the initial tetanus immunization schedule, the recommended booster for
an adolescent or adult is every ten years or less if a traumatic injury occurs that is contaminated
by dirt, feces, soil, or saliva, such as puncture or crushing injuries, avulsions, wounds from
missiles, burns, or frostbite. The adolescent's injury is considered a contaminated wound
requiring prophylactic therapy, so the tetanus toxoid booster should be administered (C). (A, B,
and D) are not indicated.
A 17-year-old male student reports to the school clinic one morning for a scheduled health
exam. He tells the nurse that he just finished football practice and is on his way to class. The
nurse assesses his vital signs: temperature 100° F, pulse 80, respirations 20, and blood
pressure 122/82. What is the best action for the nurse to take?
Tell the student to proceed directly to his regularly scheduled class.
Call the parent and suggest re-taking the student's temperature at home.
Give the student a glass of cool fluids, then retake his temperature.
Send the student to class, but re-verify his temperature after lunch. - ANS - Tell the student to
proceed directly to his regularly scheduled class.
This student has just completed football practice, and increased muscle activity increases body
heat production. A temperature of 100° F is normal for this student at this time. The student
should attend class (A) since no further nursing action is required. (B) would alarm the parents
unnecessarily. (C) would provide a false reading of body temperature. (D) is unnecessary since
these findings are within normal limits.
A 2-year-old child recently diagnosed with hemophilia A is discharged home. What information
should the nurse include in a teaching plan about home care?
Minimize interactive play with other children to lessen chances for injury.
Give low-dose children's chewable aspirin in orange flavor for joint discomfort.
Use a firm and dry toothbrush to clean teeth at least twice per day.
Apply pressure and ice for bleeding while elevating and resting the extremity. - ANS - Apply
pressure and ice for bleeding while elevating and resting the extremity.
, Hemophilia, a blood disorder, causes joint bleeding which is treated with rest, ice, compression,
and elevation (RICE) (D). (A, B, and C) are inaccurate.
A 2-year-old child with Down syndrome is brought to the clinic for his regular physical
examination. The nurse knows which problem is frequently associated with Down syndrome?
Congenital heart disease.
Fragile X chromosome.
Trisomy 13.
Pyloric stenosis. - ANS - Congenital heart disease.
Congenital heart disease (A) is the most common associated defect in children with Down
syndrome. (C) might have seemed possible since Down syndrome is a trisomal chromosomal
abnormality of chromosome 21. (B) is a sex-linked abnormality also causing mental retardation.
(D) is not associated with Down syndrome.
A 2-year-old child with gastro-esophageal reflux has developed a fear of eating. What
instruction should the nurse include in the parents' teaching plan?
Invite other children home to share meals.
Accept that he will eat when he is hungry.
Reward the child with a nap after eating.
Consistently follow a set mealtime routine. - ANS - Consistently follow a set mealtime routine.
A 2-year-old child is comforted by consistency (D). (A) is contraindicated because two-year-olds
may participate in parallel activities with other children but are too young to feel comfort and
support by the presence of other children when anxious or afraid. (B) may or may not be true
and does not address the child's fears. The child with reflux should remain upright at least two
hours after eating (C) to reduce symptoms.
A 3-month-old infant develops oral thrush. Which pharmacologic agent should the nurse plan to
administer for treatment of this disorder?
Nystatin (Mycostatin).
Nitrofurantoin (Macrodantin).
Norfloxacin (Noroxin).
Neomycin sulfate (Mycifradin). - ANS - Nystatin (Mycostatin).
Nystatin (Mycostatin) (A) is an antifungal drug that is effective in treating thrush, an oral fungal
infection. (B, C, and D) are not indicated for the treatment of oral thrush.
A 3-week-old newborn is brought to the clinic for follow-up after a home birth. The mother
reports that her child bottle feeds for 5 minutes only and then falls asleep. The nurse
auscultates a loud murmur characteristic of a ventricular septal defect (VSD), and finds the
newborn is acyanotic with a respiratory rate of 64 breaths per minute. What instruction should
