HESI Pediatric Questions and Answers.
1. A nurse in the emergency department is caring for a 2-year-old child who
was found by his parents crying and holding a container of toilet bowl
cleaner. The child's lips are edematous and inflamed, and he is drooling.
Which of the following is the priority action by the nurse?
a. Remove the child's contaminated clothing.
b. Check the child's respiratory status.
c. Administer an antidote to the child.
d. Establish IV access for the child.
Rationale: The nurse should apply the ABC priority-setting framework when
answering this item. This framework emphasizes the basic core of human
functioning: having an open airway, being able to breathe in adequate
amounts of oxygen, and circulating oxygen to the body's organs via the
blood. An alteration in any of these can indicate a threat to life, and is
therefore the nurse’s priority concern. When applying the ABC priority
setting framework, airway is always the highest priority because the airway
must be clear and open for oxygen exchange to occur. Breathing is the
second highest priority in the ABC priority setting framework because
adequate ventilatory effort is essential in order for oxygen exchange to
occur. Circulation is the third highest priority in the ABC priority setting
framework because delivery of oxygen to critical organs only occurs if the
heart and blood vessels are capable of efficiently carrying oxygen to them.
The nurse observes that the child’s lips are edematous and inflamed and
that he is drooling. These findings indicate that the child might have
swelling of the oral cavity and pharynx, which can result in a compromised
airway.
2. A nurse is teaching a parent of a 12-month old child about development
during the toddler years. Which of the following statements should the
nurse include?
a. "Your child should be referring to himself using the appropriate pronoun
by 18 months of age."
b. "A toddler's interest in looking at pictures occurs at 20 months of age."
,c. "A toddler should have daytime control of his bowel and bladder by 24
months of age."
d. "Your child should be able to scribble spontaneously using a crayon at
the age of 15
months."
Rationale: The nurse should teach the parent that at the age of 15 months,
the toddler should be able to scribble spontaneously, and at the age of 18
months, the toddler should be able to make strokes imitatively.
3. A nurse is caring for a toddler and is preparing to administer 0.9%
sodium chloride 100 mL IV to infuse over 4 hr.The drop factor of the
manual IV tubing is 60gtt/mL.The nurse should set the manual IV infusion
to deliver how many gtt/min?(Round the answer to the nearest whole
number. Use a Leading zerO if it applies. Do not use a trailing zero.)
25 gtt
Rationale: 100ml/4 hr x 60gtt/1mlx 1 hr/60min= 6000/240= 25 gtt
Ratio and Proportion
STEP 1: What is the unit of measurement to calculate? gtt/min
STEP 2: What is the volume needed? 100 mL
STEP 3: What is the total infusion time? 4 hr
STEP 4: Should the nurse convert the units of measurement? Yes (min
does not equal hr)
1 hr/60 min = 4 hr/X min
X = 240 min
STEP 5: Set up an equation and solve for X.
, Volume (mL)/Time (min) = drop factor (gtt/mL) = X
100 mL/240 min x 60 gtt/mL = X gtt/min
X = 25
STEP 6: Round if necessary.
STEP 7: Reassess to determine whether the amount to administer makes
sense. If the prescription reads 100 ml of 0.9% sodium chloride IV to infuse
over 4 hr, it makes sense to administer 25 gtt/min. The nurse should set the
manual IV infusion to deliver0.9% sodium chloride IV at 25 gtt/min.
Dimensional Analysis
STEP 1: What is the unit of measurement to calculate? gtt/min
STEP 2: What is the volume needed? 100 mL
STEP 3: What is the total infusion time? 4 hr
STEP 4: Should the nurse convert the units of measurement? Yes (min
does not equal hr)
STEP 5: Set up an equation and solve for X.
X = Quantity / 1 mL x Conversion (hr) / Conversion (min) x Volume (mL) /
Time (hr)
X gtt/min = 60 gtt/1 mL x 1 hr/ 60 min x 100 mL/4 hr
X = 25
STEP 6: Round if necessary.
1. A nurse in the emergency department is caring for a 2-year-old child who
was found by his parents crying and holding a container of toilet bowl
cleaner. The child's lips are edematous and inflamed, and he is drooling.
Which of the following is the priority action by the nurse?
a. Remove the child's contaminated clothing.
b. Check the child's respiratory status.
c. Administer an antidote to the child.
d. Establish IV access for the child.
Rationale: The nurse should apply the ABC priority-setting framework when
answering this item. This framework emphasizes the basic core of human
functioning: having an open airway, being able to breathe in adequate
amounts of oxygen, and circulating oxygen to the body's organs via the
blood. An alteration in any of these can indicate a threat to life, and is
therefore the nurse’s priority concern. When applying the ABC priority
setting framework, airway is always the highest priority because the airway
must be clear and open for oxygen exchange to occur. Breathing is the
second highest priority in the ABC priority setting framework because
adequate ventilatory effort is essential in order for oxygen exchange to
occur. Circulation is the third highest priority in the ABC priority setting
framework because delivery of oxygen to critical organs only occurs if the
heart and blood vessels are capable of efficiently carrying oxygen to them.
The nurse observes that the child’s lips are edematous and inflamed and
that he is drooling. These findings indicate that the child might have
swelling of the oral cavity and pharynx, which can result in a compromised
airway.
2. A nurse is teaching a parent of a 12-month old child about development
during the toddler years. Which of the following statements should the
nurse include?
a. "Your child should be referring to himself using the appropriate pronoun
by 18 months of age."
b. "A toddler's interest in looking at pictures occurs at 20 months of age."
,c. "A toddler should have daytime control of his bowel and bladder by 24
months of age."
d. "Your child should be able to scribble spontaneously using a crayon at
the age of 15
months."
Rationale: The nurse should teach the parent that at the age of 15 months,
the toddler should be able to scribble spontaneously, and at the age of 18
months, the toddler should be able to make strokes imitatively.
3. A nurse is caring for a toddler and is preparing to administer 0.9%
sodium chloride 100 mL IV to infuse over 4 hr.The drop factor of the
manual IV tubing is 60gtt/mL.The nurse should set the manual IV infusion
to deliver how many gtt/min?(Round the answer to the nearest whole
number. Use a Leading zerO if it applies. Do not use a trailing zero.)
25 gtt
Rationale: 100ml/4 hr x 60gtt/1mlx 1 hr/60min= 6000/240= 25 gtt
Ratio and Proportion
STEP 1: What is the unit of measurement to calculate? gtt/min
STEP 2: What is the volume needed? 100 mL
STEP 3: What is the total infusion time? 4 hr
STEP 4: Should the nurse convert the units of measurement? Yes (min
does not equal hr)
1 hr/60 min = 4 hr/X min
X = 240 min
STEP 5: Set up an equation and solve for X.
, Volume (mL)/Time (min) = drop factor (gtt/mL) = X
100 mL/240 min x 60 gtt/mL = X gtt/min
X = 25
STEP 6: Round if necessary.
STEP 7: Reassess to determine whether the amount to administer makes
sense. If the prescription reads 100 ml of 0.9% sodium chloride IV to infuse
over 4 hr, it makes sense to administer 25 gtt/min. The nurse should set the
manual IV infusion to deliver0.9% sodium chloride IV at 25 gtt/min.
Dimensional Analysis
STEP 1: What is the unit of measurement to calculate? gtt/min
STEP 2: What is the volume needed? 100 mL
STEP 3: What is the total infusion time? 4 hr
STEP 4: Should the nurse convert the units of measurement? Yes (min
does not equal hr)
STEP 5: Set up an equation and solve for X.
X = Quantity / 1 mL x Conversion (hr) / Conversion (min) x Volume (mL) /
Time (hr)
X gtt/min = 60 gtt/1 mL x 1 hr/ 60 min x 100 mL/4 hr
X = 25
STEP 6: Round if necessary.
