HESI/Saunders Online Review For The NCLEX-RN
Examination Questions With Correct Verified
Answers Rationales
A nurse is preparing to administer an injection of vitamin K to a
newborn. At which site would the nurse select to administer the
medication?
1) area of greater trochanter
2) area of the femoral vein
3) lateral aspect of the middle third of the vastus lateralis
4) patellar area -Answer:-3
Rationale: The preferred injection site for the administration of
vitamin K in the newborn is the lateral aspect of the middle third of
the vastus lateralis muscle (the newborn's thigh). This muscle is the
preferred injection site because it is free of major blood vessels and
nerves and is large enough to absorb the medication. Option 1 is the
area of the greater trochanter. Option 2 is the area of the femoral
vein. Option 4 is the patellar area.
,A nurse reviewing the medical history of an infant experiencing
gastroesophageal reflux (GER) would expect to note documentation
of:
A) Refusal to suck Incorrect
B) Frequent diarrhea
C) Recurrent otitis media
D) Inability to pass stools -Answer:-C
Rationale: GER is regurgitation of gastric contents back into the
esophagus. The three types of GER are physiologic, functional, and
pathologic. Vomiting or spitting up after a meal, hiccupping, and
recurrent otitis media resulting from pooling of secretions in the
nasopharynx during sleep are characteristics of all types of GER.
Refusal to suck, diarrhea, and inability to pass stools are not
associated with GER.
In caring for a child admitted to the hospital with Kawasaki disease,
the nurse should monitor the child most closely for signs of:
A) Anemia
B) Renal failure
C) Thrombus formation
,D) Gastrointestinal disturbances -Answer:-C
Rationale: Kawasaki disease, also called mucocutaneous lymph
node syndrome, is an acute febrile exanthematous illness of children
with a generalized vasculitis of unknown origin. A generalized
immune response affects the smooth muscle cells of the vascular
walls. These vascular changes, along with the increase in platelets
that occurs as part of the disease, can cause thrombus formation,
myocardial infarction, and death in some children. Anemia, renal
failure, and gastrointestinal disturbances are not specifically
associated with this disorder.
A nurse provides dietary instructions to the mother of a child with
iron-deficiency anemia. The nurse should tell the mother that the
food highest in iron is:
A) Milk
B) Cheese
C) Orange juice
D) Cream of Wheat -Answer:-D
Rationale: Foods high in iron include liver, dried beans, Cream of
Wheat, iron-fortified cereal, apricots and prunes (and other dried
, fruits), egg yolks, and dark-green leafy vegetables. Milk and cheese
are high in calcium. Orange juice is high in vitamin C.
A nurse provides home care instructions to an adolescent with
sickle cell disease about measures to prevent vaso-occlusive crisis.
The nurse should tell the adolescent to:
A) Restrict fluid intake
B) Take ibuprofen (Motrin) for discomfort
C) Take acetylsalicylic acid (aspirin) immediately if a fever develops
D) Be sure to spend plenty of time in the fresh air and sun each day -
Answer:-B
Rationale: The adolescent with sickle cell disease is advised to take
acetaminophen (Tylenol) or ibuprofen (Motrin) if discomfort occurs.
The use of aspirin is avoided. The adolescent is instructed to contact
the physician if a fever develops. Dehydration is avoided, and the
adolescent is instructed to consume adequate fluids. Cold and heat
stress and prolonged exposure to the sun are avoided because they
can cause dehydration, which may precipitate a crisis.
Examination Questions With Correct Verified
Answers Rationales
A nurse is preparing to administer an injection of vitamin K to a
newborn. At which site would the nurse select to administer the
medication?
1) area of greater trochanter
2) area of the femoral vein
3) lateral aspect of the middle third of the vastus lateralis
4) patellar area -Answer:-3
Rationale: The preferred injection site for the administration of
vitamin K in the newborn is the lateral aspect of the middle third of
the vastus lateralis muscle (the newborn's thigh). This muscle is the
preferred injection site because it is free of major blood vessels and
nerves and is large enough to absorb the medication. Option 1 is the
area of the greater trochanter. Option 2 is the area of the femoral
vein. Option 4 is the patellar area.
,A nurse reviewing the medical history of an infant experiencing
gastroesophageal reflux (GER) would expect to note documentation
of:
A) Refusal to suck Incorrect
B) Frequent diarrhea
C) Recurrent otitis media
D) Inability to pass stools -Answer:-C
Rationale: GER is regurgitation of gastric contents back into the
esophagus. The three types of GER are physiologic, functional, and
pathologic. Vomiting or spitting up after a meal, hiccupping, and
recurrent otitis media resulting from pooling of secretions in the
nasopharynx during sleep are characteristics of all types of GER.
Refusal to suck, diarrhea, and inability to pass stools are not
associated with GER.
In caring for a child admitted to the hospital with Kawasaki disease,
the nurse should monitor the child most closely for signs of:
A) Anemia
B) Renal failure
C) Thrombus formation
,D) Gastrointestinal disturbances -Answer:-C
Rationale: Kawasaki disease, also called mucocutaneous lymph
node syndrome, is an acute febrile exanthematous illness of children
with a generalized vasculitis of unknown origin. A generalized
immune response affects the smooth muscle cells of the vascular
walls. These vascular changes, along with the increase in platelets
that occurs as part of the disease, can cause thrombus formation,
myocardial infarction, and death in some children. Anemia, renal
failure, and gastrointestinal disturbances are not specifically
associated with this disorder.
A nurse provides dietary instructions to the mother of a child with
iron-deficiency anemia. The nurse should tell the mother that the
food highest in iron is:
A) Milk
B) Cheese
C) Orange juice
D) Cream of Wheat -Answer:-D
Rationale: Foods high in iron include liver, dried beans, Cream of
Wheat, iron-fortified cereal, apricots and prunes (and other dried
, fruits), egg yolks, and dark-green leafy vegetables. Milk and cheese
are high in calcium. Orange juice is high in vitamin C.
A nurse provides home care instructions to an adolescent with
sickle cell disease about measures to prevent vaso-occlusive crisis.
The nurse should tell the adolescent to:
A) Restrict fluid intake
B) Take ibuprofen (Motrin) for discomfort
C) Take acetylsalicylic acid (aspirin) immediately if a fever develops
D) Be sure to spend plenty of time in the fresh air and sun each day -
Answer:-B
Rationale: The adolescent with sickle cell disease is advised to take
acetaminophen (Tylenol) or ibuprofen (Motrin) if discomfort occurs.
The use of aspirin is avoided. The adolescent is instructed to contact
the physician if a fever develops. Dehydration is avoided, and the
adolescent is instructed to consume adequate fluids. Cold and heat
stress and prolonged exposure to the sun are avoided because they
can cause dehydration, which may precipitate a crisis.
