HESI/SAUNDERS REVIEW EXAM||
QUESTIONS AND ANSWERS ()
(VERIFIED ANSWERS)
A nurse is teaching the mother of a child with diarrhea about signs and symptoms that
require a call to the physician. Which of the following statements by the mother
indicates a need for further instruction?
A) "I'll call the doctor if she gets dizzy and acts sick."
B) "I'll call the doctor if she has severe stomach cramps."
C) "I'll call the doctor if her temperature is 102° or higher."
D) "I'll call the physician if she goes longer than 6 hours without urinating." Answer
Answer: C
Rationale: The mother should call the physician if a fever over 100° F, especially one
lasting longer than 72 hours, develops. She should not wait until the temperature climbs
to 102° F. The remaining statements are all correct because the findings suggest
possible dehydration and hypovolemia. In addition, severe abdominal cramps could
indicate an acute problem.
A nurse is going to administer a vitamin K injection to a newborn. To which of the
following sites will the nurse 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 Answer: 3
Rationale: The site of choice for vitamin K injection in the newborn is the lateral aspect
of the middle third of the vastus lateralis muscle - the middle third of the infant's thigh. It
is the site of choice because it does not contain major blood vessels and nerves and is
,big enough to take up the medication. Option 1 is the area of the greater trochanter.
Option 2 reflects the area of the femoral vein. Option 4 indicates the area of the patella.
A nurse utilizing a medical history for an infant diagnosed with gastroesophageal reflux
would anticipate noting the presence of:
,A) Refusal to suck Incorrect
B) Frequent diarrhea
C) Recurrent otitis media
D) Inability to pass stools - Answer Answer: C
Rationale: GER is the retrograde movement of gastric contents into the esophagus. The
three types of GER include physiologic, functional, and pathologic. Vomiting or spitting
up after feeding, hiccupping, and recurrent otitis media related to pooling of secretions
in the nasopharynx during sleep are common to all three types of GER. Fussiness and
refusal to suck, diarrhea, and inability to pass stools are not related to GER.
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 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 involves the smooth muscle cells of the vascular
walls. These vascular changes, in concert with the increase in platelets that occurs as a
part of the disease, may result in thrombus formation, myocardial infarction, and death
in some children. Anemia, renal failure, and gastrointestinal disturbances are not
specifically associated with this disorder.
A nurse is providing dietary instructions to the mother of a child diagnosed with
iron-deficiency anemia. The nurse should inform the mother that the following food is
highest in iron:
A) Milk
B) Cheese
C) Orange juice
D) Cream of Wheat - Answer Answer: D
Rationale: Iron-rich foods include liver, dried beans, Cream of Wheat, iron-fortified
cereal, apricots and prunes (and other dried fruits), egg yolks, and dark-green leafy
, vegetables. Foods rich in calcium include milk and cheese. Orange juice is rich in
vitamin C.
A nurse is teaching a teenager patient with sickle cell disease about the ways to prevent
vaso-occlusive crisis. The nurse should teach the client to:
A) Restrict fluid intake
B) Ibuprofen (Motrin) may be given for discomfort
C) Immediately give acetylsalicylic acid (aspirin) once a fever has started
D) Patient must spend a lot of time in fresh air and sun daily - Answer Answer: B
Rationale: The adolescent with sickle cell disease is treated with the recommendation to
take acetaminophen (Tylenol) or ibuprofen (Motrin) if discomfort occurs. The use of
aspirin is avoided. Instruct the adolescent to call the physician if a fever develops. Avoid
dehydration by instructing the adolescent to consume adequate fluids. Also avoid cold
and heat stress and prolonged exposure to the sun because it may cause dehydration,
which can precipitate a crisis.
A nurse is reviewing the record of a child suspected of having acute poststreptococcal
glomerulonephritis and notes that the child recently had a streptococcal throat infection
treated with antibiotics. Which of the following physician prescriptions that will confirm
the diagnosis of acute poststreptococcal glomerulonephritis does the nurse expect to
find?
A) Throat culture
B) Blood urea nitrogen (BUN)
C) Antistreptolysin (ASO) titer
D) White blood cell (WBC) count - Answer Answer: C
Rationale: Immunologic studies are helpful in the diagnosis of acute poststreptococcal
glomerulonephritis. The ASO titer, representing antibodies to the streptococcal
bacteria, may be elevated. Culture of the throat may be useful in identifying the
bacterium; however, this test is helpful only if the infection is acute and the child has not
received antibiotics. The BUN level would be elevated if renal insufficiency was
occurring. The WBC count is usually normal. Throat culture, BUN and WBC count would
not confirm the diagnosis of acute poststreptococcal glomerulonephritis.
The nurse is caring for the client who begins to seize while in bed. Which of the following
QUESTIONS AND ANSWERS ()
(VERIFIED ANSWERS)
A nurse is teaching the mother of a child with diarrhea about signs and symptoms that
require a call to the physician. Which of the following statements by the mother
indicates a need for further instruction?
A) "I'll call the doctor if she gets dizzy and acts sick."
B) "I'll call the doctor if she has severe stomach cramps."
C) "I'll call the doctor if her temperature is 102° or higher."
D) "I'll call the physician if she goes longer than 6 hours without urinating." Answer
Answer: C
Rationale: The mother should call the physician if a fever over 100° F, especially one
lasting longer than 72 hours, develops. She should not wait until the temperature climbs
to 102° F. The remaining statements are all correct because the findings suggest
possible dehydration and hypovolemia. In addition, severe abdominal cramps could
indicate an acute problem.
A nurse is going to administer a vitamin K injection to a newborn. To which of the
following sites will the nurse 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 Answer: 3
Rationale: The site of choice for vitamin K injection in the newborn is the lateral aspect
of the middle third of the vastus lateralis muscle - the middle third of the infant's thigh. It
is the site of choice because it does not contain major blood vessels and nerves and is
,big enough to take up the medication. Option 1 is the area of the greater trochanter.
Option 2 reflects the area of the femoral vein. Option 4 indicates the area of the patella.
A nurse utilizing a medical history for an infant diagnosed with gastroesophageal reflux
would anticipate noting the presence of:
,A) Refusal to suck Incorrect
B) Frequent diarrhea
C) Recurrent otitis media
D) Inability to pass stools - Answer Answer: C
Rationale: GER is the retrograde movement of gastric contents into the esophagus. The
three types of GER include physiologic, functional, and pathologic. Vomiting or spitting
up after feeding, hiccupping, and recurrent otitis media related to pooling of secretions
in the nasopharynx during sleep are common to all three types of GER. Fussiness and
refusal to suck, diarrhea, and inability to pass stools are not related to GER.
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 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 involves the smooth muscle cells of the vascular
walls. These vascular changes, in concert with the increase in platelets that occurs as a
part of the disease, may result in thrombus formation, myocardial infarction, and death
in some children. Anemia, renal failure, and gastrointestinal disturbances are not
specifically associated with this disorder.
A nurse is providing dietary instructions to the mother of a child diagnosed with
iron-deficiency anemia. The nurse should inform the mother that the following food is
highest in iron:
A) Milk
B) Cheese
C) Orange juice
D) Cream of Wheat - Answer Answer: D
Rationale: Iron-rich foods include liver, dried beans, Cream of Wheat, iron-fortified
cereal, apricots and prunes (and other dried fruits), egg yolks, and dark-green leafy
, vegetables. Foods rich in calcium include milk and cheese. Orange juice is rich in
vitamin C.
A nurse is teaching a teenager patient with sickle cell disease about the ways to prevent
vaso-occlusive crisis. The nurse should teach the client to:
A) Restrict fluid intake
B) Ibuprofen (Motrin) may be given for discomfort
C) Immediately give acetylsalicylic acid (aspirin) once a fever has started
D) Patient must spend a lot of time in fresh air and sun daily - Answer Answer: B
Rationale: The adolescent with sickle cell disease is treated with the recommendation to
take acetaminophen (Tylenol) or ibuprofen (Motrin) if discomfort occurs. The use of
aspirin is avoided. Instruct the adolescent to call the physician if a fever develops. Avoid
dehydration by instructing the adolescent to consume adequate fluids. Also avoid cold
and heat stress and prolonged exposure to the sun because it may cause dehydration,
which can precipitate a crisis.
A nurse is reviewing the record of a child suspected of having acute poststreptococcal
glomerulonephritis and notes that the child recently had a streptococcal throat infection
treated with antibiotics. Which of the following physician prescriptions that will confirm
the diagnosis of acute poststreptococcal glomerulonephritis does the nurse expect to
find?
A) Throat culture
B) Blood urea nitrogen (BUN)
C) Antistreptolysin (ASO) titer
D) White blood cell (WBC) count - Answer Answer: C
Rationale: Immunologic studies are helpful in the diagnosis of acute poststreptococcal
glomerulonephritis. The ASO titer, representing antibodies to the streptococcal
bacteria, may be elevated. Culture of the throat may be useful in identifying the
bacterium; however, this test is helpful only if the infection is acute and the child has not
received antibiotics. The BUN level would be elevated if renal insufficiency was
occurring. The WBC count is usually normal. Throat culture, BUN and WBC count would
not confirm the diagnosis of acute poststreptococcal glomerulonephritis.
The nurse is caring for the client who begins to seize while in bed. Which of the following
