Evolve HESI Peds COMPREHENSIVE EXAM
QUESTIONS WITH DETAILED VERIFIED AND
100% CORRECT ANSWERS BRAND NEW EXAM
ALREADY GRADED A+
Save
Terms in this set (85)
A 6-month-old infant with Apical heart rate of 60.
congestive heart failure (CHF) is
receiving digoxin elixir. Which A heart rate of 60 (A) is much lower than normal
observation by the nurse warrants for a 6-month-old and warrants immediate
immediate intervention? intervention. The normal heart rate for a 6-month-
Apical heart rate of 60. old is 80 to 150 BPM when awake, and a rate of
Sweating across the forehead. 70 while sleeping is considered within normal
Doesn't suck well. limits. (B and C) are expected symptoms of heart
Respiratory rate of 30 breaths per failure in an infant. (D) is within normal limits for
minute. an infant.
,The nurse is teaching the parents of Administer aerosol therapy followed by postural
a 5-year-old with cystic fibrosis drainage before meals.
about respiratory treatments. Which
statement indicates to the nurse Postural drainage for a child with cystic fibrosis is
that the parents understand? most effective when performed after
Perform postural drainage before nebulization and before meals (C) or at least 1
starting aerosol therapy. hour after eating to prevent nausea and vomiting.
Give respiratory treatments when Postural drainage uses gravity to promote
the child is coughing a lot. mucous removal after nebulization (A) treatments
Administer aerosol therapy which open the airways. Pulmonary toileting or
followed by postural drainage respiratory treatments should be given 3 to 4
before meals. times daily, not episodically (B and D).
Ensure respiratory therapy is done
daily during any respiratory
infection.
A female teenager is taking oral Use sunscreen when lying by the pool.
tetracycline HCL (Achromycin V) for
acne vulgaris. What is the most Photosensitivity is a common side effect of
important instruction for the nurse tetracycline HCL (Achromycin V) therapy. Severe
to include in this client's teaching sunburn can occur with minimal sun exposure
plan? and clients should be instructed to avoid sunlight
Use sunscreen when lying by the and to use sunscreen (A). (B and D) are not
pool. related to tetracycline HCL (Achromycin V)
Cleanse the skin at least 4 times a therapy. (C) should be avoided because dairy
day. products interfere with the absorption of
Take the medication with a glass of tetracyclines.
milk.
Menstrual periods may become
irregular.
,What preoperative nursing Observe for projectile vomiting.
intervention should be included in
the plan of care for an infant with Projectile vomiting (D), which contributes to
pyloric stenosis? metabolic alkalosis (A), is the classic sign of
Monitor for signs of metabolic pyloric stenosis. (B) is not indicated. (C) is
acidosis. dangerous, due to the potential for aspiration
Estimate the quantity of diarrhea with frequent vomiting.
stools.
Place in a supine position after
feeding.
Observe for projectile vomiting.
An infant is born with a ventricular Prevent the return of oxygenated blood to the
septal defect (VSD) and surgery is lungs.
planned to correct the defect. The
nurse recognizes that surgical Closure of VSDs stops oxygenated blood from
correction is designed to achieve being shunted from the left ventricle to the right
which outcome? ventricle (C). VSDs are acyanotic defects, which
Stop the flow of unoxygenated means that no unoxygenated blood enters the
blood into systemic circulation. systemic circulation (A and B). (D) is common with
Increase the flow of unoxygenated Tetrology of Fallot, which is a cyanotic defect.
blood to the lungs.
Prevent the return of oxygenated
blood to the lungs.
Reduce peripheral tissue hypoxia
and nailbed clubbing
, A 3-week-old newborn is brought A. Monitor the the infant's weight and number of
to the clinic for follow-up after a wet diapers per day.
home birth. The mother reports that B. Increase the infant's intake per feeding by 1 to
her child bottle feeds for 5 minutes 2 ounces per week.
only and then falls asleep. The D. Allow the infant to rest and refeed on demand
nurse auscultates a loud murmur or every 2 hours.
characteristic of a ventricular septal E. Use a softer nipple or increase the size of the
defect (VSD), and finds the nipple opening.
newborn is acyanotic with a
respiratory rate of 64 breaths per Antibiotic prophylaxis is recommended for
minute. What instruction should the infants with VSDs, but should not be mixed in a
nurse provide the mother to ensure bottle of formula (C) because it is difficult to
the infant is receiving adequate ensure that the total dose is consumed.
intake? (Select all that apply.)
A. Monitor the the infant's weight They should be monitored for weight gain and at
and number of wet diapers per day. least 6 wet diapers per day (A). A one-month old
B. Increase the infant's intake per infant should ingest 2 to 4 ounces of formula per
feeding by 1 to 2 ounces per week. feeding and progress to about 30 ounces per
C. Mix the dose of prophylactic day by 4-months of age (B)
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.
Preoperative nursing care for a Put a sign on the bed reading, "DO NOT PALPATE
child with Wilms' tumor should ABDOMEN."
include which intervention?
Gently percuss the abdomen for Prevention of abdominal palpation (D) minimizes
evidence of trapped air. the risk of rupturing the encapsulated tumor and
Observe the abdomen for any subsequent metastasis. (A) is unnecessary, and
noticeable discolorations. this action could traumatize the tumor in the
Apply cold compresses to the same manner as palpation. (B and C) are
abdomen to reduce edema. incorrect since the abdomen is not discolored
Put a sign on the bed reading, "DO and cold compresses are not indicated.
NOT PALPATE ABDOMEN."
QUESTIONS WITH DETAILED VERIFIED AND
100% CORRECT ANSWERS BRAND NEW EXAM
ALREADY GRADED A+
Save
Terms in this set (85)
A 6-month-old infant with Apical heart rate of 60.
congestive heart failure (CHF) is
receiving digoxin elixir. Which A heart rate of 60 (A) is much lower than normal
observation by the nurse warrants for a 6-month-old and warrants immediate
immediate intervention? intervention. The normal heart rate for a 6-month-
Apical heart rate of 60. old is 80 to 150 BPM when awake, and a rate of
Sweating across the forehead. 70 while sleeping is considered within normal
Doesn't suck well. limits. (B and C) are expected symptoms of heart
Respiratory rate of 30 breaths per failure in an infant. (D) is within normal limits for
minute. an infant.
,The nurse is teaching the parents of Administer aerosol therapy followed by postural
a 5-year-old with cystic fibrosis drainage before meals.
about respiratory treatments. Which
statement indicates to the nurse Postural drainage for a child with cystic fibrosis is
that the parents understand? most effective when performed after
Perform postural drainage before nebulization and before meals (C) or at least 1
starting aerosol therapy. hour after eating to prevent nausea and vomiting.
Give respiratory treatments when Postural drainage uses gravity to promote
the child is coughing a lot. mucous removal after nebulization (A) treatments
Administer aerosol therapy which open the airways. Pulmonary toileting or
followed by postural drainage respiratory treatments should be given 3 to 4
before meals. times daily, not episodically (B and D).
Ensure respiratory therapy is done
daily during any respiratory
infection.
A female teenager is taking oral Use sunscreen when lying by the pool.
tetracycline HCL (Achromycin V) for
acne vulgaris. What is the most Photosensitivity is a common side effect of
important instruction for the nurse tetracycline HCL (Achromycin V) therapy. Severe
to include in this client's teaching sunburn can occur with minimal sun exposure
plan? and clients should be instructed to avoid sunlight
Use sunscreen when lying by the and to use sunscreen (A). (B and D) are not
pool. related to tetracycline HCL (Achromycin V)
Cleanse the skin at least 4 times a therapy. (C) should be avoided because dairy
day. products interfere with the absorption of
Take the medication with a glass of tetracyclines.
milk.
Menstrual periods may become
irregular.
,What preoperative nursing Observe for projectile vomiting.
intervention should be included in
the plan of care for an infant with Projectile vomiting (D), which contributes to
pyloric stenosis? metabolic alkalosis (A), is the classic sign of
Monitor for signs of metabolic pyloric stenosis. (B) is not indicated. (C) is
acidosis. dangerous, due to the potential for aspiration
Estimate the quantity of diarrhea with frequent vomiting.
stools.
Place in a supine position after
feeding.
Observe for projectile vomiting.
An infant is born with a ventricular Prevent the return of oxygenated blood to the
septal defect (VSD) and surgery is lungs.
planned to correct the defect. The
nurse recognizes that surgical Closure of VSDs stops oxygenated blood from
correction is designed to achieve being shunted from the left ventricle to the right
which outcome? ventricle (C). VSDs are acyanotic defects, which
Stop the flow of unoxygenated means that no unoxygenated blood enters the
blood into systemic circulation. systemic circulation (A and B). (D) is common with
Increase the flow of unoxygenated Tetrology of Fallot, which is a cyanotic defect.
blood to the lungs.
Prevent the return of oxygenated
blood to the lungs.
Reduce peripheral tissue hypoxia
and nailbed clubbing
, A 3-week-old newborn is brought A. Monitor the the infant's weight and number of
to the clinic for follow-up after a wet diapers per day.
home birth. The mother reports that B. Increase the infant's intake per feeding by 1 to
her child bottle feeds for 5 minutes 2 ounces per week.
only and then falls asleep. The D. Allow the infant to rest and refeed on demand
nurse auscultates a loud murmur or every 2 hours.
characteristic of a ventricular septal E. Use a softer nipple or increase the size of the
defect (VSD), and finds the nipple opening.
newborn is acyanotic with a
respiratory rate of 64 breaths per Antibiotic prophylaxis is recommended for
minute. What instruction should the infants with VSDs, but should not be mixed in a
nurse provide the mother to ensure bottle of formula (C) because it is difficult to
the infant is receiving adequate ensure that the total dose is consumed.
intake? (Select all that apply.)
A. Monitor the the infant's weight They should be monitored for weight gain and at
and number of wet diapers per day. least 6 wet diapers per day (A). A one-month old
B. Increase the infant's intake per infant should ingest 2 to 4 ounces of formula per
feeding by 1 to 2 ounces per week. feeding and progress to about 30 ounces per
C. Mix the dose of prophylactic day by 4-months of age (B)
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.
Preoperative nursing care for a Put a sign on the bed reading, "DO NOT PALPATE
child with Wilms' tumor should ABDOMEN."
include which intervention?
Gently percuss the abdomen for Prevention of abdominal palpation (D) minimizes
evidence of trapped air. the risk of rupturing the encapsulated tumor and
Observe the abdomen for any subsequent metastasis. (A) is unnecessary, and
noticeable discolorations. this action could traumatize the tumor in the
Apply cold compresses to the same manner as palpation. (B and C) are
abdomen to reduce edema. incorrect since the abdomen is not discolored
Put a sign on the bed reading, "DO and cold compresses are not indicated.
NOT PALPATE ABDOMEN."
