HESI RN PEDS V2 EXAM QUESTIONS WITH
CORRECT ANSWERS
1.The nurse is planning postoperative care for a child who has had a cleft lip
| | | | | | | | | | | | | |
repair. What is the most important
| | | | | |
reason to minimize this child's crying during the recovery period?
| | | | | | | | |
A. Tear formation increases salivation.
| | | |
B. This behavior increases respirations.
| | | |
C. Excessive hysteria can lead to vomiting.
| | | | | |
D. Crying stresses the suture line - CORRECT ANSWER✔✔-Rationale: choice D
| | | | | | | | | |
Prevention of stress on the lip suture line is essential for optimum healing and the
| | | | | | | | | | | | | |
cosmetic appearance of a cleft
| | | | |
lip repair. Although crying also causes options A, B, and C, these conditions do not
| | | | | | | | | | | | | |
|create a problem for the child
| | | | |
with a cleft lip repair.
| | | |
An infant is receiving digoxin for congestive heart failure. The apical heart rate is
| | | | | | | | | | | | |
assessed at 80
| | |
beats/min. What intervention should the nurse implement?
| | | | | |
A. Call for a portable chest radiograph.
| | | | | |
B. Obtain a therapeutic drug level.
| | | | |
C. Reassess the heart rate in 30 minutes.
| | | | | | |
,D. Administer digoxin immune Fab stat. - CORRECT ANSWER✔✔-Rationale:
| | | | | | | |
Answer: D. | |
Sinus bradycardia (heart rate <90 to 110 beats/min in an infant) is an indication of
| | | | | | | | | | | | | |
digoxin toxicity, so assessment
| | | |
of the client's digoxin level has the highest priority. Option A is not indicated at
| | | | | | | | | | | | | |
this time. Option C provides
| | | | |
helpful assessment data but does not address the cause of the problem and
| | | | | | | | | | | |
delays needed intervention. Option D
| | | | |
is indicated for a serious, life-threatening overdose with digoxin.
| | | | | | | |
The nurse admits a child to the intensive care unit with a possible diagnosis of
| | | | | | | | | | | | | |
Wilms tumor - What is the
| | | | | |
most safety precaution for child?
| | | |
A. maintain NPO status
| | |
B. Limit visitors to the immediate family
| | | | | |
C. Place a do not palpate abdomen sign on head of
| | | | | | | | | |
bed
d encourage ambulatory in pre operative period - CORRECT ANSWER✔✔-C.
| | | | | | | | |
Protect child from injury; place a sign on bed stating "no abdominal palpation"
| | | | | | | | | | | | |
(to prevent accidental
| | |
fragmentation and dislodging into the abdominal cavity). The other option
| | | | | | | | |
|choices are not relevant at this time.
| | | | | |
,The nurse is preparing a teaching plan for the mother of a child who has been
| | | | | | | | | | | | | | |
diagnosed with celiac
| | |
disease. Choosing which lunch will be within the therapeutic management of a
| | | | | | | | | | |
child with celiac disease?
| | | |
A. Turkey salad, milk, and oatmeal cookies
| | | | | |
B. Baked chicken, coleslaw, soda, and frozen fruit
| | | | | | |
dessert
C. Tuna salad sandwich on whole wheat bread, milk, and ice cream
| | | | | | | | | | |
D. Turkey sandwich on rye bread, orange juice, and fresh fruit - CORRECT
| | | | | | | | | | | |
ANSWER✔✔-Correct Answer: B
| | |
Rationale:
A child with celiac disease is managed on a gluten-free diet, which eliminates
| | | | | | | | | | | |
food products containing oats, wheat, rye, or barley.
| | | | | | | |
A 6-month-old male infant is admitted to the postanesthesia care unit with elbow
| | | | | | | | | | | |
restraints in place. He
| | | |
has an endotracheal tube and is ventilator-dependent but will be extubated soon
| | | | | | | | | | |
following recovery from
| | |
anesthesia. Which nursing intervention should be included in this child's plan of
| | | | | | | | | | |
care?
|
A. Keep restraints on at all times to prevent unplanned extubation.
| | | | | | | | | |
B. Remove restraints one at a time and provide range-of-motion exercises.
| | | | | | | | | |
C. Remove all restraints simultaneously and provide play activities
| | | | | | | |
D. Document the reason for application of the restraints every 72 hours. -
| | | | | | | | | | | |
CORRECT ANSWER✔✔-Remove restraints one at a time and provide range-of-
| | | | | | | | | |
motion exercises. |
, Removing restraints one at a time is safer than option C. The infant should have
| | | | | | | | | | | | | |
the restrained extremities assessed frequently for signs of neurologic or vascular
| | | | | | | | | | |
impairment, and range-of-motion exercises should be performed with these
| | | | | | | | |
assessments. Under no circumstances should restraints be applied to the client
| | | | | | | | | | |
continuously. Documentation of assessment findings regarding the restrained
| | | | | | | |
extremities must occur much more frequently than every 72 hours; however, the
| | | | | | | | | | | |
reason for using restraints must be justified and should be stated in the medical
| | | | | | | | | | | | | |
record.
|
The nurse assigns an unlicensed assistive personnel (UP) to provide morning care
| | | | | | | | | | |
to a newly admitted
| | | |
child with bacterial meningitis. What is the most important instruction for the
| | | | | | | | | | |
nurse to review with the UP?
| | | | | | |
A.Use designated isolation precautions.
| | |
B. Keep the lighting in the room dim.
| | | | | | |
C. Allow the parents to assist with care
| | | | | | |
D. Report any pain that the child experiences - CORRECT ANSWER✔✔-A.
| | | | | | | | | | |
Rationale:
All these are important measures to review with the UP, but the most important
| | | | | | | | | | | | |
is option A. Improper use of
| | | | | |
isolation precautions can place other staff and clients at risk for infection. Options
| | | | | | | | | | | |
|B. C, and D promote client
| | | | |
comfort and reduce anxiety but are of a lower priority than option A.
| | | | | | | | | | | |
The nurse is caring for a child with intussusception who is scheduled for a barium
| | | | | | | | | | | | | |
enema prior to a
| | | |
CORRECT ANSWERS
1.The nurse is planning postoperative care for a child who has had a cleft lip
| | | | | | | | | | | | | |
repair. What is the most important
| | | | | |
reason to minimize this child's crying during the recovery period?
| | | | | | | | |
A. Tear formation increases salivation.
| | | |
B. This behavior increases respirations.
| | | |
C. Excessive hysteria can lead to vomiting.
| | | | | |
D. Crying stresses the suture line - CORRECT ANSWER✔✔-Rationale: choice D
| | | | | | | | | |
Prevention of stress on the lip suture line is essential for optimum healing and the
| | | | | | | | | | | | | |
cosmetic appearance of a cleft
| | | | |
lip repair. Although crying also causes options A, B, and C, these conditions do not
| | | | | | | | | | | | | |
|create a problem for the child
| | | | |
with a cleft lip repair.
| | | |
An infant is receiving digoxin for congestive heart failure. The apical heart rate is
| | | | | | | | | | | | |
assessed at 80
| | |
beats/min. What intervention should the nurse implement?
| | | | | |
A. Call for a portable chest radiograph.
| | | | | |
B. Obtain a therapeutic drug level.
| | | | |
C. Reassess the heart rate in 30 minutes.
| | | | | | |
,D. Administer digoxin immune Fab stat. - CORRECT ANSWER✔✔-Rationale:
| | | | | | | |
Answer: D. | |
Sinus bradycardia (heart rate <90 to 110 beats/min in an infant) is an indication of
| | | | | | | | | | | | | |
digoxin toxicity, so assessment
| | | |
of the client's digoxin level has the highest priority. Option A is not indicated at
| | | | | | | | | | | | | |
this time. Option C provides
| | | | |
helpful assessment data but does not address the cause of the problem and
| | | | | | | | | | | |
delays needed intervention. Option D
| | | | |
is indicated for a serious, life-threatening overdose with digoxin.
| | | | | | | |
The nurse admits a child to the intensive care unit with a possible diagnosis of
| | | | | | | | | | | | | |
Wilms tumor - What is the
| | | | | |
most safety precaution for child?
| | | |
A. maintain NPO status
| | |
B. Limit visitors to the immediate family
| | | | | |
C. Place a do not palpate abdomen sign on head of
| | | | | | | | | |
bed
d encourage ambulatory in pre operative period - CORRECT ANSWER✔✔-C.
| | | | | | | | |
Protect child from injury; place a sign on bed stating "no abdominal palpation"
| | | | | | | | | | | | |
(to prevent accidental
| | |
fragmentation and dislodging into the abdominal cavity). The other option
| | | | | | | | |
|choices are not relevant at this time.
| | | | | |
,The nurse is preparing a teaching plan for the mother of a child who has been
| | | | | | | | | | | | | | |
diagnosed with celiac
| | |
disease. Choosing which lunch will be within the therapeutic management of a
| | | | | | | | | | |
child with celiac disease?
| | | |
A. Turkey salad, milk, and oatmeal cookies
| | | | | |
B. Baked chicken, coleslaw, soda, and frozen fruit
| | | | | | |
dessert
C. Tuna salad sandwich on whole wheat bread, milk, and ice cream
| | | | | | | | | | |
D. Turkey sandwich on rye bread, orange juice, and fresh fruit - CORRECT
| | | | | | | | | | | |
ANSWER✔✔-Correct Answer: B
| | |
Rationale:
A child with celiac disease is managed on a gluten-free diet, which eliminates
| | | | | | | | | | | |
food products containing oats, wheat, rye, or barley.
| | | | | | | |
A 6-month-old male infant is admitted to the postanesthesia care unit with elbow
| | | | | | | | | | | |
restraints in place. He
| | | |
has an endotracheal tube and is ventilator-dependent but will be extubated soon
| | | | | | | | | | |
following recovery from
| | |
anesthesia. Which nursing intervention should be included in this child's plan of
| | | | | | | | | | |
care?
|
A. Keep restraints on at all times to prevent unplanned extubation.
| | | | | | | | | |
B. Remove restraints one at a time and provide range-of-motion exercises.
| | | | | | | | | |
C. Remove all restraints simultaneously and provide play activities
| | | | | | | |
D. Document the reason for application of the restraints every 72 hours. -
| | | | | | | | | | | |
CORRECT ANSWER✔✔-Remove restraints one at a time and provide range-of-
| | | | | | | | | |
motion exercises. |
, Removing restraints one at a time is safer than option C. The infant should have
| | | | | | | | | | | | | |
the restrained extremities assessed frequently for signs of neurologic or vascular
| | | | | | | | | | |
impairment, and range-of-motion exercises should be performed with these
| | | | | | | | |
assessments. Under no circumstances should restraints be applied to the client
| | | | | | | | | | |
continuously. Documentation of assessment findings regarding the restrained
| | | | | | | |
extremities must occur much more frequently than every 72 hours; however, the
| | | | | | | | | | | |
reason for using restraints must be justified and should be stated in the medical
| | | | | | | | | | | | | |
record.
|
The nurse assigns an unlicensed assistive personnel (UP) to provide morning care
| | | | | | | | | | |
to a newly admitted
| | | |
child with bacterial meningitis. What is the most important instruction for the
| | | | | | | | | | |
nurse to review with the UP?
| | | | | | |
A.Use designated isolation precautions.
| | |
B. Keep the lighting in the room dim.
| | | | | | |
C. Allow the parents to assist with care
| | | | | | |
D. Report any pain that the child experiences - CORRECT ANSWER✔✔-A.
| | | | | | | | | | |
Rationale:
All these are important measures to review with the UP, but the most important
| | | | | | | | | | | | |
is option A. Improper use of
| | | | | |
isolation precautions can place other staff and clients at risk for infection. Options
| | | | | | | | | | | |
|B. C, and D promote client
| | | | |
comfort and reduce anxiety but are of a lower priority than option A.
| | | | | | | | | | | |
The nurse is caring for a child with intussusception who is scheduled for a barium
| | | | | | | | | | | | | |
enema prior to a
| | | |
