NUR 131 HESI EAQ Practice Exam 3 practice
test questions correctly defined a+
guaranteed
Which early sign of impending hydrocephalus would the nurse monitor for in an
infant who has had surgery for repair of a myelomeningocele?
(1) Frequent crying
(2) Bulging fontanels
(3) Change in vital signs
(4) Difficulty with feeding - n
ANS✔
(2) Bulging fontanels
RATIONALE:
(1) after closure spinal fluid can buildup and reach the brain causing an increase in
ICP and thus bulging fontanels
Qs
would the nurse document on the child's clinical record? Select all that apply. One,
some, or all responses may be correct.
(1) Intake and output
(2) Measurement of pain
(3) Tolerance of low-residue diet
(4) Frequency of dressing changes
(5) Presence or absence of bowel sounds - n
ANS✔
(1) Intake and output
(2) Measurement of pain
(5) Presence or absence of bowel sounds
,RATIONALE:
(1) pain is assessed because a laparoscopic surgery involves insufflating the
abdomen with air which will cause pain until it's reabsorbed
(2) checking for bowel sounds with help determine how the child is adapting to the
intestinal trauma caused by the surgery
Qs
Which is the most important safety measure for the nurse to institute immediately
when a 2-year-old child has a seizure?
(1) Monitoring the child's vital signs
(2) Padding the side rails of the toddler's crib
(3) Placing the child in the side-lying position
(4) Bringing suction equipment to the bedside - n
ANS✔
(3) Placing the child in the side-lying position
RATIONALE:
(1) maintaining a patent airway is the priority and the side-lying position helps
promote that by keeping the tongue away from the back of the pharynx and
allowing saliva to flow out by gravity
Qs
When assessing a toddler with autism spectrum disorder (ASD), which
characteristic findings or behaviors would the nurse expect? Select all that apply.
One, some, or all responses may be correct.
(1) The desire to hug the nurse
(2) Flat, blank facial expression
(3) Laughing when pulse is taken
(4) Inability to maintain eye contact
(5) Enjoys climbing on stairs and furniture - n
, ANS✔
(2) Flat, blank facial expression
(3) Laughing when pulse is taken
(4) Inability to maintain eye contact
RATIONALE:
(1) characteristics expected from a toddler with ASD would be a flat effect,
inappropriate laughing while measuring pulse, lack of eye contact, and
humming/grunting
(2) tend to over-respond to environmental stimuli
(3) will rarely hug anyone and would not enjoy climbing on furniture
Qs
While assessing a client's hair, the nurse notices the client has head lice. The nurse
teaches the client about hair hygiene and lice control. Which client statement
indicates an understanding of the teaching? Select all that apply. One, some, or all
responses may be correct.
(1) "I will clean my comb in ammonia water."
(2) "I should use lindane-containing shampoo."
(3) "I should shampoo my hair in a tub or shower."
(4) "I should use a dilute vinegar solution to loosen the nits."
(5) "I should use a shampoo treatment once every 24 hours." - n
ANS✔
(1) "I will clean my comb in ammonia water."
(4) "I should use a dilute vinegar solution to loosen the nits."
(5) "I should use a shampoo treatment once every 24 hours."
Qs
recommendations for lice treatment - n
ANS✔
(1) lindane can be used but could have serious side effects
, (2) should not wash hair in tub or shower because this could cause the lice to be
able to migrate to other spots
(3) soaking combs in ammonia water can help enhance lice control
(4) nits can be loosened with dilute vinegar solution
(5) shampooing should be done at least once every 24-48 hours
Qs
Which pathophysiological rationale explains why a client who is 4 days
postabdominal surgery has not passed flatus and has hypoactive bowel sounds and
why a paralytic ileus is suspected of developing?
(1) Decreased blood supply
(2) Impaired neural functioning
(3) Perforation of the bowel wall
(4) Obstruction of the bowel lumen - n
ANS✔
(2) Impaired neural functioning
RATIONALE:
(1) paralytic ileus occurs when neurological impulses diminish result from
anesthesia, infection, or surgery
Qs
necrosis results when..? - n
ANS✔
there is an interference in blood supply
Qs
s/s of perforation of the bowel include - n
ANS✔
(1) pain
(2) peritonitis
test questions correctly defined a+
guaranteed
Which early sign of impending hydrocephalus would the nurse monitor for in an
infant who has had surgery for repair of a myelomeningocele?
(1) Frequent crying
(2) Bulging fontanels
(3) Change in vital signs
(4) Difficulty with feeding - n
ANS✔
(2) Bulging fontanels
RATIONALE:
(1) after closure spinal fluid can buildup and reach the brain causing an increase in
ICP and thus bulging fontanels
Qs
would the nurse document on the child's clinical record? Select all that apply. One,
some, or all responses may be correct.
(1) Intake and output
(2) Measurement of pain
(3) Tolerance of low-residue diet
(4) Frequency of dressing changes
(5) Presence or absence of bowel sounds - n
ANS✔
(1) Intake and output
(2) Measurement of pain
(5) Presence or absence of bowel sounds
,RATIONALE:
(1) pain is assessed because a laparoscopic surgery involves insufflating the
abdomen with air which will cause pain until it's reabsorbed
(2) checking for bowel sounds with help determine how the child is adapting to the
intestinal trauma caused by the surgery
Qs
Which is the most important safety measure for the nurse to institute immediately
when a 2-year-old child has a seizure?
(1) Monitoring the child's vital signs
(2) Padding the side rails of the toddler's crib
(3) Placing the child in the side-lying position
(4) Bringing suction equipment to the bedside - n
ANS✔
(3) Placing the child in the side-lying position
RATIONALE:
(1) maintaining a patent airway is the priority and the side-lying position helps
promote that by keeping the tongue away from the back of the pharynx and
allowing saliva to flow out by gravity
Qs
When assessing a toddler with autism spectrum disorder (ASD), which
characteristic findings or behaviors would the nurse expect? Select all that apply.
One, some, or all responses may be correct.
(1) The desire to hug the nurse
(2) Flat, blank facial expression
(3) Laughing when pulse is taken
(4) Inability to maintain eye contact
(5) Enjoys climbing on stairs and furniture - n
, ANS✔
(2) Flat, blank facial expression
(3) Laughing when pulse is taken
(4) Inability to maintain eye contact
RATIONALE:
(1) characteristics expected from a toddler with ASD would be a flat effect,
inappropriate laughing while measuring pulse, lack of eye contact, and
humming/grunting
(2) tend to over-respond to environmental stimuli
(3) will rarely hug anyone and would not enjoy climbing on furniture
Qs
While assessing a client's hair, the nurse notices the client has head lice. The nurse
teaches the client about hair hygiene and lice control. Which client statement
indicates an understanding of the teaching? Select all that apply. One, some, or all
responses may be correct.
(1) "I will clean my comb in ammonia water."
(2) "I should use lindane-containing shampoo."
(3) "I should shampoo my hair in a tub or shower."
(4) "I should use a dilute vinegar solution to loosen the nits."
(5) "I should use a shampoo treatment once every 24 hours." - n
ANS✔
(1) "I will clean my comb in ammonia water."
(4) "I should use a dilute vinegar solution to loosen the nits."
(5) "I should use a shampoo treatment once every 24 hours."
Qs
recommendations for lice treatment - n
ANS✔
(1) lindane can be used but could have serious side effects
, (2) should not wash hair in tub or shower because this could cause the lice to be
able to migrate to other spots
(3) soaking combs in ammonia water can help enhance lice control
(4) nits can be loosened with dilute vinegar solution
(5) shampooing should be done at least once every 24-48 hours
Qs
Which pathophysiological rationale explains why a client who is 4 days
postabdominal surgery has not passed flatus and has hypoactive bowel sounds and
why a paralytic ileus is suspected of developing?
(1) Decreased blood supply
(2) Impaired neural functioning
(3) Perforation of the bowel wall
(4) Obstruction of the bowel lumen - n
ANS✔
(2) Impaired neural functioning
RATIONALE:
(1) paralytic ileus occurs when neurological impulses diminish result from
anesthesia, infection, or surgery
Qs
necrosis results when..? - n
ANS✔
there is an interference in blood supply
Qs
s/s of perforation of the bowel include - n
ANS✔
(1) pain
(2) peritonitis
