HESI EXIT V4 160 Questions and Answers
The nurse is caring for a pre-adolescent client in skeletal Dunlop
traction. Which nursing intervention is appropriate for this child?
A) Make certain the child is maintained in correct body alignment.
B) Be sure the traction weights touch the end of the bed.
C) Adjust the head and foot of the bed for the child's comfort
D) Release the traction for 15-20 minutes every 6 hours PRN.
The correct answer is A: Make certain the child is maintained in correct body
alignment.
The nurse is assessing a healthy child at the 2 year check up. Which of
the following should the nurse report immediately to the health care
provider?
A) Height and weight percentiles vary widely
B) Growth pattern appears to have slowed
C) Recumbent and standing height are different
D) Short term weight changes are uneven
The correct answer is A: Height and weight percentiles vary widely
, A postpartum mother is unwilling to allow the father to participate in
the newborn's care, although he is interested in doing so. She states, "I am
afraid the baby will be confused about who the mother is. Baby raising is
for mothers, not fathers." The nurse's initial intervention should be what
focus?
A) Discuss with the mother sharing parenting responsibilities
B) Set time aside to get the mother to express her feelings and concerns
C) Arrange for the parents to attend infant care classes
D) Talk with the father and help him accept the wife's decision
The correct answer is B: Set time aside to get the mother to express her feelings
and concerns
, A client with emphysema visits the clinic. While teaching about proper
nutrition, the nurse should emphasize that the client
A) Eat foods high in sodium increases sputum liquefaction
B) Use oxygen during meals improves gas exchange
C) Perform exercise after respiratory therapy enhances appetite
D) Cleanse the mouth of dried secretions reduces risk of infection
The correct answer is B: Use oxygen during meals improves gas exchange
Which of these parents’ comment for a newborn would most likely
reveal an initial finding of a suspected pyloric stenosis?
A) I noticed a little lump a little above the belly button.
B) The baby seems hungry all the time.
C) Mild vomiting that progressed to vomiting shooting across the room.
D) Irritation and spitting up immediately after feedings.
The correct answer is C: Mild emesis progressing to projectile vomiting
The nurse is assessing a child for clinical manifestations of iron
deficiency anemia. Which factor would the nurse recognize as cause for
the findings?
, A) Decreased cardiac output
B) Tissue hypoxia
C) Cerebral edema
D) Reduced oxygen saturation
The correct answer is B: Tissue hypoxia
The parents of a 2 year-old child report that he has been holding his breath
whenever he has temper tantrums. What is the best action by the nurse?
A) Teach the parents how to perform cardiopulmonary resuscitation
B) Recommend that the parents give in when he holds his breath to prevent
anoxia
C) Advise the parents to ignore breath holding because breathing will begin as a
reflex
D) Instruct the parents on how to reason with the child about possible
harmful effects The correct answer is C: Advise the parents to ignore breath
holding because breathing will begin as a reflex
The nurse is caring for a pre-adolescent client in skeletal Dunlop
traction. Which nursing intervention is appropriate for this child?
A) Make certain the child is maintained in correct body alignment.
B) Be sure the traction weights touch the end of the bed.
C) Adjust the head and foot of the bed for the child's comfort
D) Release the traction for 15-20 minutes every 6 hours PRN.
The correct answer is A: Make certain the child is maintained in correct body
alignment.
The nurse is assessing a healthy child at the 2 year check up. Which of
the following should the nurse report immediately to the health care
provider?
A) Height and weight percentiles vary widely
B) Growth pattern appears to have slowed
C) Recumbent and standing height are different
D) Short term weight changes are uneven
The correct answer is A: Height and weight percentiles vary widely
, A postpartum mother is unwilling to allow the father to participate in
the newborn's care, although he is interested in doing so. She states, "I am
afraid the baby will be confused about who the mother is. Baby raising is
for mothers, not fathers." The nurse's initial intervention should be what
focus?
A) Discuss with the mother sharing parenting responsibilities
B) Set time aside to get the mother to express her feelings and concerns
C) Arrange for the parents to attend infant care classes
D) Talk with the father and help him accept the wife's decision
The correct answer is B: Set time aside to get the mother to express her feelings
and concerns
, A client with emphysema visits the clinic. While teaching about proper
nutrition, the nurse should emphasize that the client
A) Eat foods high in sodium increases sputum liquefaction
B) Use oxygen during meals improves gas exchange
C) Perform exercise after respiratory therapy enhances appetite
D) Cleanse the mouth of dried secretions reduces risk of infection
The correct answer is B: Use oxygen during meals improves gas exchange
Which of these parents’ comment for a newborn would most likely
reveal an initial finding of a suspected pyloric stenosis?
A) I noticed a little lump a little above the belly button.
B) The baby seems hungry all the time.
C) Mild vomiting that progressed to vomiting shooting across the room.
D) Irritation and spitting up immediately after feedings.
The correct answer is C: Mild emesis progressing to projectile vomiting
The nurse is assessing a child for clinical manifestations of iron
deficiency anemia. Which factor would the nurse recognize as cause for
the findings?
, A) Decreased cardiac output
B) Tissue hypoxia
C) Cerebral edema
D) Reduced oxygen saturation
The correct answer is B: Tissue hypoxia
The parents of a 2 year-old child report that he has been holding his breath
whenever he has temper tantrums. What is the best action by the nurse?
A) Teach the parents how to perform cardiopulmonary resuscitation
B) Recommend that the parents give in when he holds his breath to prevent
anoxia
C) Advise the parents to ignore breath holding because breathing will begin as a
reflex
D) Instruct the parents on how to reason with the child about possible
harmful effects The correct answer is C: Advise the parents to ignore breath
holding because breathing will begin as a reflex
