HESI Peds EXAM VERIFIED SOLUTIONS,
SCORED A+
A .6-month-old .infant .with .congestive .heart .failure .(CHF) .is .receiving .digoxin
.elixir. .Which .observation .by .the .nurse .warrants .immediate .intervention?
.Apical .heart .rate .of .60.
.Sweating .across .the .forehead.
.Doesn't .suck .well.
.Respiratory .rate .of .30 .breaths .per .minute. .- .CORRECT .ANSWER-Apical .heart
.rate .of .60.
A .heart .rate .of .60 .(A) .is .much .lower .than .normal .for .a .6-month-old .and
.warrants .immediate .intervention. .The .normal .heart .rate .for .a .6-month-old .is .80
.to .150 .BPM .when .awake, .and .a .rate .of .70 .while .sleeping .is .considered .within
.normal .limits. .(B .and .C) .are .expected .symptoms .of .heart .failure .in .an .infant.
.(D) .is .within .normal .limits .for .an .infant.
The .nurse .is .teaching .the .parents .of .a .5-year-old .with .cystic .fibrosis .about
.respiratory .treatments. .Which .statement .indicates .to .the .nurse .that .the .parents
.understand?
.Perform .postural .drainage .before .starting .aerosol .therapy.
.Give .respiratory .treatments .when .the .child .is .coughing .a .lot.
.Administer .aerosol .therapy .followed .by .postural .drainage .before .meals.
.Ensure .respiratory .therapy .is .done .daily .during .any .respiratory .infection. .-
.CORRECT .ANSWER-Administer .aerosol .therapy .followed .by .postural .drainage
.before .meals.
Postural .drainage .for .a .child .with .cystic .fibrosis .is .most .effective .when
.performed .after .nebulization .and .before .meals .(C) .or .at .least .1 .hour .after
.eating .to .prevent .nausea .and .vomiting. .Postural .drainage .uses .gravity .to
.promote .mucous .removal .after .nebulization .(A) .treatments .which .open .the
.airways. .Pulmonary .toileting .or .respiratory .treatments .should .be .given .3 .to .4
.times .daily, .not .episodically .(B .and .D).
A .female .teenager .is .taking .oral .tetracycline .HCL .(Achromycin .V) .for .acne
.vulgaris. .What .is .the .most .important .instruction .for .the .nurse .to .include .in .this
.client's .teaching .plan?
.Use .sunscreen .when .lying .by .the .pool. .
.Cleanse .the .skin .at .least .4 .times .a .day.
.Take .the .medication .with .a .glass .of .milk.
.Menstrual .periods .may .become .irregular. .- .CORRECT .ANSWER-Use .sunscreen
.when .lying .by .the .pool. .
,Photosensitivity .is .a .common .side .effect .of .tetracycline .HCL .(Achromycin .V)
.therapy. .Severe .sunburn .can .occur .with .minimal .sun .exposure .and .clients
.should .be .instructed .to .avoid .sunlight .and .to .use .sunscreen .(A). .(B .and .D) .are
.not .related .to .tetracycline .HCL .(Achromycin .V) .therapy. .(C) .should .be .avoided
.because .dairy .products .interfere .with .the .absorption .of .tetracyclines.
What .preoperative .nursing .intervention .should .be .included .in .the .plan .of .care
.for .an .infant .with .pyloric .stenosis?
.Monitor .for .signs .of .metabolic .acidosis.
.Estimate .the .quantity .of .diarrhea .stools.
.Place .in .a .supine .position .after .feeding.
.Observe .for .projectile .vomiting. .- .CORRECT .ANSWER-Observe .for .projectile
.vomiting.
Projectile .vomiting .(D), .which .contributes .to .metabolic .alkalosis .(A), .is .the
.classic .sign .of .pyloric .stenosis. .(B) .is .not .indicated. .(C) .is .dangerous, .due .to
.the .potential .for .aspiration .with .frequent .vomiting.
An .infant .is .born .with .a .ventricular .septal .defect .(VSD) .and .surgery .is .planned
.to .correct .the .defect. .The .nurse .recognizes .that .surgical .correction .is .designed
.to .achieve .which .outcome?
.Stop .the .flow .of .unoxygenated .blood .into .systemic .circulation.
.Increase .the .flow .of .unoxygenated .blood .to .the .lungs. .
.Prevent .the .return .of .oxygenated .blood .to .the .lungs. .
.Reduce .peripheral .tissue .hypoxia .and .nailbed .clubbing .- .CORRECT .ANSWER-
Prevent .the .return .of .oxygenated .blood .to .the .lungs. .
Closure .of .VSDs .stops .oxygenated .blood .from .being .shunted .from .the .left
.ventricle .to .the .right .ventricle .(C). .VSDs .are .acyanotic .defects, .which .means
.that .no .unoxygenated .blood .enters .the .systemic .circulation .(A .and .B). .(D) .is
.common .with .Tetrology .of .Fallot, .which .is .a .cyanotic .defect.
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 .the .nurse .provide .the
.mother .to .ensure .the .infant .is .receiving .adequate .intake? .(Select .all .that
.apply.)
A. .Monitor .the .the .infant's .weight .and .number .of .wet .diapers .per .day. .
B. .Increase .the .infant's .intake .per .feeding .by .1 .to .2 .ounces .per .week. .
C. .Mix .the .dose .of .prophylactic .antibiotic .in .a .full .bottle .of .formula.
D. .Allow .the .infant .to .rest .and .refeed .on .demand .or .every .2 .hours.
E. .Use .a .softer .nipple .or .increase .the .size .of .the .nipple .opening. .- .CORRECT
.ANSWER-A. .Monitor .the .the .infant's .weight .and .number .of .wet .diapers .per .day.
B. .Increase .the .infant's .intake .per .feeding .by .1 .to .2 .ounces .per .week. .
D. .Allow .the .infant .to .rest .and .refeed .on .demand .or .every .2 .hours.
E. .Use .a .softer .nipple .or .increase .the .size .of .the .nipple .opening.
, Antibiotic .prophylaxis .is .recommended .for .infants .with .VSDs, .but .should .not
.be .mixed .in .a .bottle .of .formula .(C) .because .it .is .difficult .to .ensure .that .the
.total .dose .is .consumed.
They .should .be .monitored .for .weight .gain .and .at .least .6 .wet .diapers .per .day
.(A). .A .one-month .old .infant .should .ingest .2 .to .4 .ounces .of .formula .per .feeding
.and .progress .to .about .30 .ounces .per .day .by .4-months .of .age .(B)
Preoperative .nursing .care .for .a .child .with .Wilms' .tumor .should .include .which
.intervention?
.Gently .percuss .the .abdomen .for .evidence .of .trapped .air.
.Observe .the .abdomen .for .any .noticeable .discolorations.
.Apply .cold .compresses .to .the .abdomen .to .reduce .edema.
.Put .a .sign .on .the .bed .reading, ."DO .NOT .PALPATE .ABDOMEN." .- .CORRECT
.ANSWER-Put .a .sign .on .the .bed .reading, ."DO .NOT .PALPATE .ABDOMEN."
Prevention .of .abdominal .palpation .(D) .minimizes .the .risk .of .rupturing .the
.encapsulated .tumor .and .subsequent .metastasis. .(A) .is .unnecessary, .and .this
.action .could .traumatize .the .tumor .in .the .same .manner .as .palpation. .(B .and .C)
.are .incorrect .since .the .abdomen .is .not .discolored .and .cold .compresses .are
.not .indicated.
At .8 .a.m. .the .unlicensed .assistive .personnel .(UAP) .informs .the .charge .nurse
.that .a .female .adolescent .client .with .acute .glomerulonephritis .has .a .blood
.pressure .of .210/110. .The .4 .a.m. .blood .pressure .reading .was .170/88. .The .client
.reports .to .the .UAP .that .she .is .upset .because .her .boyfriend .did .not .visit .last
.night. .What .action .should .the .nurse .take .first?
.Give .the .client .her .9 .a.m. .prescription .for .an .oral .diuretic .early.
.Administer .PRN .prescription .of .nifedipine .(Procardia) .sublingually. .
.Notify .the .healthcare .provider .and .inform .the .nursing .supervisor .of .the .client's
.condition.
.Attempt .to .calm .the .client .and .retake .the .blood .pressure .in .thirty .minutes. .-
.CORRECT .ANSWER-Administer .PRN .prescription .of .nifedipine .(Procardia)
.sublingually.
Sublingual .Procardia .(B) .lowers .blood .pressure .very .quickly, .and .this .should
.be .done .first. .(A) .may .also .be .done, .but .oral .diuretics .do .not .work .as .rapidly
.as .the .sublingual .antihypertensive. .When .notifying .the .healthcare .provider, .the
.first .thing .he/she .will .want .to .know .is .if .the .PRN .antihypertensive .has .been
.administered .(C). .(D) .does .not .consider .the .seriousness .of .this .finding. .The
.nurse .should .stay .with .the .client .until .the .blood .pressure .is .reduced.
The .nurse .is .assessing .an .8-month-old .child .who .has .a .medical .diagnosis .of
.Tetrology .of .Fallot. .Which .symptom .is .this .client .most .likely .to .exhibit?
.Bradycardia.
.Machinery .murmur.
.Weak .pedal .pulses.
.Clubbed .fingers. .- .CORRECT .ANSWER-Clubbed .fingers. .
SCORED A+
A .6-month-old .infant .with .congestive .heart .failure .(CHF) .is .receiving .digoxin
.elixir. .Which .observation .by .the .nurse .warrants .immediate .intervention?
.Apical .heart .rate .of .60.
.Sweating .across .the .forehead.
.Doesn't .suck .well.
.Respiratory .rate .of .30 .breaths .per .minute. .- .CORRECT .ANSWER-Apical .heart
.rate .of .60.
A .heart .rate .of .60 .(A) .is .much .lower .than .normal .for .a .6-month-old .and
.warrants .immediate .intervention. .The .normal .heart .rate .for .a .6-month-old .is .80
.to .150 .BPM .when .awake, .and .a .rate .of .70 .while .sleeping .is .considered .within
.normal .limits. .(B .and .C) .are .expected .symptoms .of .heart .failure .in .an .infant.
.(D) .is .within .normal .limits .for .an .infant.
The .nurse .is .teaching .the .parents .of .a .5-year-old .with .cystic .fibrosis .about
.respiratory .treatments. .Which .statement .indicates .to .the .nurse .that .the .parents
.understand?
.Perform .postural .drainage .before .starting .aerosol .therapy.
.Give .respiratory .treatments .when .the .child .is .coughing .a .lot.
.Administer .aerosol .therapy .followed .by .postural .drainage .before .meals.
.Ensure .respiratory .therapy .is .done .daily .during .any .respiratory .infection. .-
.CORRECT .ANSWER-Administer .aerosol .therapy .followed .by .postural .drainage
.before .meals.
Postural .drainage .for .a .child .with .cystic .fibrosis .is .most .effective .when
.performed .after .nebulization .and .before .meals .(C) .or .at .least .1 .hour .after
.eating .to .prevent .nausea .and .vomiting. .Postural .drainage .uses .gravity .to
.promote .mucous .removal .after .nebulization .(A) .treatments .which .open .the
.airways. .Pulmonary .toileting .or .respiratory .treatments .should .be .given .3 .to .4
.times .daily, .not .episodically .(B .and .D).
A .female .teenager .is .taking .oral .tetracycline .HCL .(Achromycin .V) .for .acne
.vulgaris. .What .is .the .most .important .instruction .for .the .nurse .to .include .in .this
.client's .teaching .plan?
.Use .sunscreen .when .lying .by .the .pool. .
.Cleanse .the .skin .at .least .4 .times .a .day.
.Take .the .medication .with .a .glass .of .milk.
.Menstrual .periods .may .become .irregular. .- .CORRECT .ANSWER-Use .sunscreen
.when .lying .by .the .pool. .
,Photosensitivity .is .a .common .side .effect .of .tetracycline .HCL .(Achromycin .V)
.therapy. .Severe .sunburn .can .occur .with .minimal .sun .exposure .and .clients
.should .be .instructed .to .avoid .sunlight .and .to .use .sunscreen .(A). .(B .and .D) .are
.not .related .to .tetracycline .HCL .(Achromycin .V) .therapy. .(C) .should .be .avoided
.because .dairy .products .interfere .with .the .absorption .of .tetracyclines.
What .preoperative .nursing .intervention .should .be .included .in .the .plan .of .care
.for .an .infant .with .pyloric .stenosis?
.Monitor .for .signs .of .metabolic .acidosis.
.Estimate .the .quantity .of .diarrhea .stools.
.Place .in .a .supine .position .after .feeding.
.Observe .for .projectile .vomiting. .- .CORRECT .ANSWER-Observe .for .projectile
.vomiting.
Projectile .vomiting .(D), .which .contributes .to .metabolic .alkalosis .(A), .is .the
.classic .sign .of .pyloric .stenosis. .(B) .is .not .indicated. .(C) .is .dangerous, .due .to
.the .potential .for .aspiration .with .frequent .vomiting.
An .infant .is .born .with .a .ventricular .septal .defect .(VSD) .and .surgery .is .planned
.to .correct .the .defect. .The .nurse .recognizes .that .surgical .correction .is .designed
.to .achieve .which .outcome?
.Stop .the .flow .of .unoxygenated .blood .into .systemic .circulation.
.Increase .the .flow .of .unoxygenated .blood .to .the .lungs. .
.Prevent .the .return .of .oxygenated .blood .to .the .lungs. .
.Reduce .peripheral .tissue .hypoxia .and .nailbed .clubbing .- .CORRECT .ANSWER-
Prevent .the .return .of .oxygenated .blood .to .the .lungs. .
Closure .of .VSDs .stops .oxygenated .blood .from .being .shunted .from .the .left
.ventricle .to .the .right .ventricle .(C). .VSDs .are .acyanotic .defects, .which .means
.that .no .unoxygenated .blood .enters .the .systemic .circulation .(A .and .B). .(D) .is
.common .with .Tetrology .of .Fallot, .which .is .a .cyanotic .defect.
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 .the .nurse .provide .the
.mother .to .ensure .the .infant .is .receiving .adequate .intake? .(Select .all .that
.apply.)
A. .Monitor .the .the .infant's .weight .and .number .of .wet .diapers .per .day. .
B. .Increase .the .infant's .intake .per .feeding .by .1 .to .2 .ounces .per .week. .
C. .Mix .the .dose .of .prophylactic .antibiotic .in .a .full .bottle .of .formula.
D. .Allow .the .infant .to .rest .and .refeed .on .demand .or .every .2 .hours.
E. .Use .a .softer .nipple .or .increase .the .size .of .the .nipple .opening. .- .CORRECT
.ANSWER-A. .Monitor .the .the .infant's .weight .and .number .of .wet .diapers .per .day.
B. .Increase .the .infant's .intake .per .feeding .by .1 .to .2 .ounces .per .week. .
D. .Allow .the .infant .to .rest .and .refeed .on .demand .or .every .2 .hours.
E. .Use .a .softer .nipple .or .increase .the .size .of .the .nipple .opening.
, Antibiotic .prophylaxis .is .recommended .for .infants .with .VSDs, .but .should .not
.be .mixed .in .a .bottle .of .formula .(C) .because .it .is .difficult .to .ensure .that .the
.total .dose .is .consumed.
They .should .be .monitored .for .weight .gain .and .at .least .6 .wet .diapers .per .day
.(A). .A .one-month .old .infant .should .ingest .2 .to .4 .ounces .of .formula .per .feeding
.and .progress .to .about .30 .ounces .per .day .by .4-months .of .age .(B)
Preoperative .nursing .care .for .a .child .with .Wilms' .tumor .should .include .which
.intervention?
.Gently .percuss .the .abdomen .for .evidence .of .trapped .air.
.Observe .the .abdomen .for .any .noticeable .discolorations.
.Apply .cold .compresses .to .the .abdomen .to .reduce .edema.
.Put .a .sign .on .the .bed .reading, ."DO .NOT .PALPATE .ABDOMEN." .- .CORRECT
.ANSWER-Put .a .sign .on .the .bed .reading, ."DO .NOT .PALPATE .ABDOMEN."
Prevention .of .abdominal .palpation .(D) .minimizes .the .risk .of .rupturing .the
.encapsulated .tumor .and .subsequent .metastasis. .(A) .is .unnecessary, .and .this
.action .could .traumatize .the .tumor .in .the .same .manner .as .palpation. .(B .and .C)
.are .incorrect .since .the .abdomen .is .not .discolored .and .cold .compresses .are
.not .indicated.
At .8 .a.m. .the .unlicensed .assistive .personnel .(UAP) .informs .the .charge .nurse
.that .a .female .adolescent .client .with .acute .glomerulonephritis .has .a .blood
.pressure .of .210/110. .The .4 .a.m. .blood .pressure .reading .was .170/88. .The .client
.reports .to .the .UAP .that .she .is .upset .because .her .boyfriend .did .not .visit .last
.night. .What .action .should .the .nurse .take .first?
.Give .the .client .her .9 .a.m. .prescription .for .an .oral .diuretic .early.
.Administer .PRN .prescription .of .nifedipine .(Procardia) .sublingually. .
.Notify .the .healthcare .provider .and .inform .the .nursing .supervisor .of .the .client's
.condition.
.Attempt .to .calm .the .client .and .retake .the .blood .pressure .in .thirty .minutes. .-
.CORRECT .ANSWER-Administer .PRN .prescription .of .nifedipine .(Procardia)
.sublingually.
Sublingual .Procardia .(B) .lowers .blood .pressure .very .quickly, .and .this .should
.be .done .first. .(A) .may .also .be .done, .but .oral .diuretics .do .not .work .as .rapidly
.as .the .sublingual .antihypertensive. .When .notifying .the .healthcare .provider, .the
.first .thing .he/she .will .want .to .know .is .if .the .PRN .antihypertensive .has .been
.administered .(C). .(D) .does .not .consider .the .seriousness .of .this .finding. .The
.nurse .should .stay .with .the .client .until .the .blood .pressure .is .reduced.
The .nurse .is .assessing .an .8-month-old .child .who .has .a .medical .diagnosis .of
.Tetrology .of .Fallot. .Which .symptom .is .this .client .most .likely .to .exhibit?
.Bradycardia.
.Machinery .murmur.
.Weak .pedal .pulses.
.Clubbed .fingers. .- .CORRECT .ANSWER-Clubbed .fingers. .
