HES EXAM 2 QUESTIONS WITH 100% CORRECT
ANSWERS 2025!!
1. 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.
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 consider
within normal limits. (B and C) are expected symptoms of heart failure in an infant. (D) is within normal limits for a
infant.
2. 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 par- ents 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.
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).
3. 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.
Answer> Use sunscreen when lying by the pool.
Photosensitivity is a common side effect of tetracycline HCL (Achromycin V) ther- apy. Severe sunburn can occ
with minimal sun exposure and clients should be instructed to avoid sunlight and to use sunscreen (A). (B and
are not related
,to tetracycline HCL (Achromycin V) therapy. (C) should be avoided because dairy products interfere with the
absorption of tetracyclines.
4. 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.
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.
5. 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
Answer> Prevent the return of oxygenated blood to the lungs.
Closure of VSDs stops oxygenated blood from being shunted from the left ven- tricle 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.
, 6. 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.
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.
ANSWERS 2025!!
1. 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.
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 consider
within normal limits. (B and C) are expected symptoms of heart failure in an infant. (D) is within normal limits for a
infant.
2. 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 par- ents 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.
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).
3. 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.
Answer> Use sunscreen when lying by the pool.
Photosensitivity is a common side effect of tetracycline HCL (Achromycin V) ther- apy. Severe sunburn can occ
with minimal sun exposure and clients should be instructed to avoid sunlight and to use sunscreen (A). (B and
are not related
,to tetracycline HCL (Achromycin V) therapy. (C) should be avoided because dairy products interfere with the
absorption of tetracyclines.
4. 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.
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.
5. 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
Answer> Prevent the return of oxygenated blood to the lungs.
Closure of VSDs stops oxygenated blood from being shunted from the left ven- tricle 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.
, 6. 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.
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.
