Evolve HESI peds Practice Questions
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Apical heart rate of 60.
A 6-month-old infant with congestive
heart failure (CHF) is receiving digoxin A heart rate of 60 (A) is much lower
elixir. Which observation by the nurse than normal for a 6-month-old and war-
warrants immediate intervention? rants immediate intervention. The normal
Apical heart rate of 60. heart rate for a 6-month-old is 80 to 150
Sweating across the forehead. BPM when awake, and a rate of 70 while
Doesn't suck well. sleeping is considered within normal lim-
Respiratory rate of 30 breaths per its. (B and C) are expected symptoms
minute. of heart failure in an infant. (D) is within
normal limits for an infant.
Administer aerosol therapy followed by
The nurse is teaching the parents of a
postural drainage before meals.
5-year-old with cystic fibrosis about res-
piratory treatments. Which statement in-
Postural drainage for a child with cystic
dicates to the nurse that the parents un-
fibrosis is most effective when performed
derstand?
after nebulization and before meals (C)
Perform postural drainage before start-
or at least 1 hour after eating to prevent
ing aerosol therapy.
nausea and vomiting. Postural drainage
Give respiratory treatments when the
uses gravity to promote mucous removal
child is coughing a lot.
after nebulization (A) treatments which
Administer aerosol therapy followed by
open the airways. Pulmonary toileting or
postural drainage before meals.
respiratory treatments should be given 3
Ensure respiratory therapy is done daily
to 4 times daily, not episodically (B and
during any respiratory infection.
D).
Use sunscreen when lying by the pool.
A female teenager is taking oral tetracy-
cline HCL (Achromycin V) for acne vul- Photosensitivity is a common side effect
garis. What is the most important instruc- of tetracycline HCL (Achromycin V) ther-
tion for the nurse to include in this client's apy. Severe sunburn can occur with min-
teaching plan? imal sun exposure and clients should be
Use sunscreen when lying by the pool. instructed to avoid sunlight and to use
Cleanse the skin at least 4 times a day. sunscreen (A). (B and D) are not related
Take the medication with a glass of milk. to tetracycline HCL (Achromycin V) ther-
Menstrual periods may become irregu- apy. (C) should be avoided because dairy
lar. products interfere with the absorption of
tetracyclines.
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What preoperative nursing intervention Observe for projectile vomiting.
should be included in the plan of care for
an infant with pyloric stenosis? Projectile vomiting (D), which contributes
Monitor for signs of metabolic acidosis. to metabolic alkalosis (A), is the classic
Estimate the quantity of diarrhea stools. sign of pyloric stenosis. (B) is not indicat-
Place in a supine position after feeding. ed. (C) is dangerous, due to the potential
Observe for projectile vomiting. for aspiration with frequent vomiting.
An infant is born with a ventricular septal
defect (VSD) and surgery is planned to Prevent the return of oxygenated blood
correct the defect. The nurse recognizes to the lungs.
that surgical correction is designed to
achieve which outcome? Closure of VSDs stops oxygenated blood
Stop the flow of unoxygenated blood into from being shunted from the left ventri-
systemic circulation. cle to the right ventricle (C). VSDs are
Increase the flow of unoxygenated blood acyanotic defects, which means that no
to the lungs. unoxygenated blood enters the systemic
Prevent the return of oxygenated blood circulation (A and B). (D) is common with
to the lungs. Tetrology of Fallot, which is a cyanotic
Reduce peripheral tissue hypoxia and defect.
nailbed clubbing
A 3-week-old newborn is brought to the A. Monitor the the infant's weight and
clinic for follow-up after a home birth. number of wet diapers per day.
The mother reports that her child bot- B. Increase the infant's intake per feeding
tle feeds for 5 minutes only and then by 1 to 2 ounces per week.
falls asleep. The nurse auscultates a loud D. Allow the infant to rest and refeed on
murmur characteristic of a ventricular demand or every 2 hours.
septal defect (VSD), and finds the new- E. Use a softer nipple or increase the size
born is acyanotic with a respiratory rate of the nipple opening.
of 64 breaths per minute. What instruc-
tion should the nurse provide the moth- Antibiotic prophylaxis is recommended
er to ensure the infant is receiving ade- for infants with VSDs, but should not be
quate intake? (Select all that apply.) mixed in a bottle of formula (C) because
A. Monitor the the infant's weight and it is difficult to ensure that the total dose
number of wet diapers per day. is consumed.
B. Increase the infant's intake per feeding
by 1 to 2 ounces per week. They should be monitored for weight gain
C. Mix the dose of prophylactic antibiotic and at least 6 wet diapers per day (A).
in a full bottle of formula. A one-month old infant should ingest 2
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D. Allow the infant to rest and refeed on
to 4 ounces of formula per feeding and
demand or every 2 hours.
progress to about 30 ounces per day by
E. Use a softer nipple or increase the
4-months of age (B)
size of the nipple opening.
Preoperative nursing care for a child with Put a sign on the bed reading, "DO NOT
Wilms' tumor should include which inter- PALPATE ABDOMEN."
vention?
Gently percuss the abdomen for evi- Prevention of abdominal palpation (D)
dence of trapped air. minimizes the risk of rupturing the encap-
Observe the abdomen for any notice- sulated tumor and subsequent metasta-
able discolorations. sis. (A) is unnecessary, and this action
Apply cold compresses to the abdomen could traumatize the tumor in the same
to reduce edema. manner as palpation. (B and C) are incor-
Put a sign on the bed reading, "DO NOT rect since the abdomen is not discolored
PALPATE ABDOMEN." and cold compresses are not indicated.
At 8 a.m. the unlicensed assistive per-
sonnel (UAP) informs the charge nurse
that a female adolescent client with Administer PRN prescription of nifedip-
acute glomerulonephritis has a blood ine (Procardia) sublingually.
pressure of 210/110. The 4 a.m. blood
pressure reading was 170/88. The client Sublingual Procardia (B) lowers blood
reports to the UAP that she is upset pressure very quickly, and this should be
because her boyfriend did not visit last done first. (A) may also be done, but oral
night. What action should the nurse take diuretics do not work as rapidly as the
first? sublingual antihypertensive. When noti-
Give the client her 9 a.m. prescription for fying the healthcare provider, the first
an oral diuretic early. thing he/she will want to know is if the
Administer PRN prescription of nifedip- PRN antihypertensive has been admin-
ine (Procardia) sublingually. istered (C). (D) does not consider the
Notify the healthcare provider and in- seriousness of this finding. The nurse
form the nursing supervisor of the client's should stay with the client until the blood
condition. pressure is reduced.
Attempt to calm the client and retake the
blood pressure in thirty minutes.
The nurse is assessing an 8-month-old Clubbed fingers.
child who has a medical diagnosis of
Tetrology of Fallot. Which symptom is Tetrology of Fallot, a cyanotic heart de-
this client most likely to exhibit? fect, causes clubbing of fingers and toes
, Evolve HESI peds Practice Questions
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(D) due to tissue hypoxia. Tachycardia,
Bradycardia.
not (A), is a manifestation of congenital
Machinery murmur.
heart disease. (B) is a classic sign of ven-
Weak pedal pulses.
tricular septal defect. (C) is characteristic
Clubbed fingers.
of coarctation of the aorta.
A trial of human chorionic gonadotrophic
hormone.
Surgery is being delayed for an infant
with undescended testes. In collabora-
A trial of HCG (human chorionic go-
tion with the healthcare provider and
nadotrophic hormone) (C) may aid in
the family, which prescription should the
testicular descent, but does not re-
nurse anticipate?
place surgical repair for true undescend-
A trial of adrenocorticotrophic hormone
ed testes. Undescended testes (cryp-
injections.
torchidism) may be found in the inguinal
Frequent stimulation of the cremasteric
canal due to exaggerated cremasteric re-
reflex.
flex. (A) is not indicated. Stimulation of
A trial of human chorionic gonadotrophic
the cremasteric reflex causes the testes
hormone.
to ascend rather than descend in the
Frequent warm baths to gently dilate the
scrotum (B). (D) may relax the cremas-
scrotal area.
teric muscle, but may not cause the
testes to descend.
Concern for body integrity.
The preschooler's major stressor is con-
cern for his body integrity (C). He fears
A preschool-age child who is hospi-
that his "insides will leak out." A child
talized for hypospadias repair is most
undergoing surgery to his genitalia is
strongly influenced by which behavior?
even more concerned about body integri-
Ability to communicate verbally.
ty. The preschooler is quite verbal, so
Response to separation from family.
comprehension of the words he uses or
Concern for body integrity.
hears may be inaccurate, while his imagi-
Socialization with other children.
nation and fears may fantasize the reality
(A). (B) is a concern for all children, but
of most concern to the toddler. (D) is not
a prime concern in this situation.
A six-month-old returns from surgery Remove restraints one at a time and pro-
with elbow restraints in place. What nurs- vide range of motion exercises.
ing care should be included when caring
Study online at https://quizlet.com/_3siog6
Apical heart rate of 60.
A 6-month-old infant with congestive
heart failure (CHF) is receiving digoxin A heart rate of 60 (A) is much lower
elixir. Which observation by the nurse than normal for a 6-month-old and war-
warrants immediate intervention? rants immediate intervention. The normal
Apical heart rate of 60. heart rate for a 6-month-old is 80 to 150
Sweating across the forehead. BPM when awake, and a rate of 70 while
Doesn't suck well. sleeping is considered within normal lim-
Respiratory rate of 30 breaths per its. (B and C) are expected symptoms
minute. of heart failure in an infant. (D) is within
normal limits for an infant.
Administer aerosol therapy followed by
The nurse is teaching the parents of a
postural drainage before meals.
5-year-old with cystic fibrosis about res-
piratory treatments. Which statement in-
Postural drainage for a child with cystic
dicates to the nurse that the parents un-
fibrosis is most effective when performed
derstand?
after nebulization and before meals (C)
Perform postural drainage before start-
or at least 1 hour after eating to prevent
ing aerosol therapy.
nausea and vomiting. Postural drainage
Give respiratory treatments when the
uses gravity to promote mucous removal
child is coughing a lot.
after nebulization (A) treatments which
Administer aerosol therapy followed by
open the airways. Pulmonary toileting or
postural drainage before meals.
respiratory treatments should be given 3
Ensure respiratory therapy is done daily
to 4 times daily, not episodically (B and
during any respiratory infection.
D).
Use sunscreen when lying by the pool.
A female teenager is taking oral tetracy-
cline HCL (Achromycin V) for acne vul- Photosensitivity is a common side effect
garis. What is the most important instruc- of tetracycline HCL (Achromycin V) ther-
tion for the nurse to include in this client's apy. Severe sunburn can occur with min-
teaching plan? imal sun exposure and clients should be
Use sunscreen when lying by the pool. instructed to avoid sunlight and to use
Cleanse the skin at least 4 times a day. sunscreen (A). (B and D) are not related
Take the medication with a glass of milk. to tetracycline HCL (Achromycin V) ther-
Menstrual periods may become irregu- apy. (C) should be avoided because dairy
lar. products interfere with the absorption of
tetracyclines.
, Evolve HESI peds Practice Questions
Study online at https://quizlet.com/_3siog6
What preoperative nursing intervention Observe for projectile vomiting.
should be included in the plan of care for
an infant with pyloric stenosis? Projectile vomiting (D), which contributes
Monitor for signs of metabolic acidosis. to metabolic alkalosis (A), is the classic
Estimate the quantity of diarrhea stools. sign of pyloric stenosis. (B) is not indicat-
Place in a supine position after feeding. ed. (C) is dangerous, due to the potential
Observe for projectile vomiting. for aspiration with frequent vomiting.
An infant is born with a ventricular septal
defect (VSD) and surgery is planned to Prevent the return of oxygenated blood
correct the defect. The nurse recognizes to the lungs.
that surgical correction is designed to
achieve which outcome? Closure of VSDs stops oxygenated blood
Stop the flow of unoxygenated blood into from being shunted from the left ventri-
systemic circulation. cle to the right ventricle (C). VSDs are
Increase the flow of unoxygenated blood acyanotic defects, which means that no
to the lungs. unoxygenated blood enters the systemic
Prevent the return of oxygenated blood circulation (A and B). (D) is common with
to the lungs. Tetrology of Fallot, which is a cyanotic
Reduce peripheral tissue hypoxia and defect.
nailbed clubbing
A 3-week-old newborn is brought to the A. Monitor the the infant's weight and
clinic for follow-up after a home birth. number of wet diapers per day.
The mother reports that her child bot- B. Increase the infant's intake per feeding
tle feeds for 5 minutes only and then by 1 to 2 ounces per week.
falls asleep. The nurse auscultates a loud D. Allow the infant to rest and refeed on
murmur characteristic of a ventricular demand or every 2 hours.
septal defect (VSD), and finds the new- E. Use a softer nipple or increase the size
born is acyanotic with a respiratory rate of the nipple opening.
of 64 breaths per minute. What instruc-
tion should the nurse provide the moth- Antibiotic prophylaxis is recommended
er to ensure the infant is receiving ade- for infants with VSDs, but should not be
quate intake? (Select all that apply.) mixed in a bottle of formula (C) because
A. Monitor the the infant's weight and it is difficult to ensure that the total dose
number of wet diapers per day. is consumed.
B. Increase the infant's intake per feeding
by 1 to 2 ounces per week. They should be monitored for weight gain
C. Mix the dose of prophylactic antibiotic and at least 6 wet diapers per day (A).
in a full bottle of formula. A one-month old infant should ingest 2
, Evolve HESI peds Practice Questions
Study online at https://quizlet.com/_3siog6
D. Allow the infant to rest and refeed on
to 4 ounces of formula per feeding and
demand or every 2 hours.
progress to about 30 ounces per day by
E. Use a softer nipple or increase the
4-months of age (B)
size of the nipple opening.
Preoperative nursing care for a child with Put a sign on the bed reading, "DO NOT
Wilms' tumor should include which inter- PALPATE ABDOMEN."
vention?
Gently percuss the abdomen for evi- Prevention of abdominal palpation (D)
dence of trapped air. minimizes the risk of rupturing the encap-
Observe the abdomen for any notice- sulated tumor and subsequent metasta-
able discolorations. sis. (A) is unnecessary, and this action
Apply cold compresses to the abdomen could traumatize the tumor in the same
to reduce edema. manner as palpation. (B and C) are incor-
Put a sign on the bed reading, "DO NOT rect since the abdomen is not discolored
PALPATE ABDOMEN." and cold compresses are not indicated.
At 8 a.m. the unlicensed assistive per-
sonnel (UAP) informs the charge nurse
that a female adolescent client with Administer PRN prescription of nifedip-
acute glomerulonephritis has a blood ine (Procardia) sublingually.
pressure of 210/110. The 4 a.m. blood
pressure reading was 170/88. The client Sublingual Procardia (B) lowers blood
reports to the UAP that she is upset pressure very quickly, and this should be
because her boyfriend did not visit last done first. (A) may also be done, but oral
night. What action should the nurse take diuretics do not work as rapidly as the
first? sublingual antihypertensive. When noti-
Give the client her 9 a.m. prescription for fying the healthcare provider, the first
an oral diuretic early. thing he/she will want to know is if the
Administer PRN prescription of nifedip- PRN antihypertensive has been admin-
ine (Procardia) sublingually. istered (C). (D) does not consider the
Notify the healthcare provider and in- seriousness of this finding. The nurse
form the nursing supervisor of the client's should stay with the client until the blood
condition. pressure is reduced.
Attempt to calm the client and retake the
blood pressure in thirty minutes.
The nurse is assessing an 8-month-old Clubbed fingers.
child who has a medical diagnosis of
Tetrology of Fallot. Which symptom is Tetrology of Fallot, a cyanotic heart de-
this client most likely to exhibit? fect, causes clubbing of fingers and toes
, Evolve HESI peds Practice Questions
Study online at https://quizlet.com/_3siog6
(D) due to tissue hypoxia. Tachycardia,
Bradycardia.
not (A), is a manifestation of congenital
Machinery murmur.
heart disease. (B) is a classic sign of ven-
Weak pedal pulses.
tricular septal defect. (C) is characteristic
Clubbed fingers.
of coarctation of the aorta.
A trial of human chorionic gonadotrophic
hormone.
Surgery is being delayed for an infant
with undescended testes. In collabora-
A trial of HCG (human chorionic go-
tion with the healthcare provider and
nadotrophic hormone) (C) may aid in
the family, which prescription should the
testicular descent, but does not re-
nurse anticipate?
place surgical repair for true undescend-
A trial of adrenocorticotrophic hormone
ed testes. Undescended testes (cryp-
injections.
torchidism) may be found in the inguinal
Frequent stimulation of the cremasteric
canal due to exaggerated cremasteric re-
reflex.
flex. (A) is not indicated. Stimulation of
A trial of human chorionic gonadotrophic
the cremasteric reflex causes the testes
hormone.
to ascend rather than descend in the
Frequent warm baths to gently dilate the
scrotum (B). (D) may relax the cremas-
scrotal area.
teric muscle, but may not cause the
testes to descend.
Concern for body integrity.
The preschooler's major stressor is con-
cern for his body integrity (C). He fears
A preschool-age child who is hospi-
that his "insides will leak out." A child
talized for hypospadias repair is most
undergoing surgery to his genitalia is
strongly influenced by which behavior?
even more concerned about body integri-
Ability to communicate verbally.
ty. The preschooler is quite verbal, so
Response to separation from family.
comprehension of the words he uses or
Concern for body integrity.
hears may be inaccurate, while his imagi-
Socialization with other children.
nation and fears may fantasize the reality
(A). (B) is a concern for all children, but
of most concern to the toddler. (D) is not
a prime concern in this situation.
A six-month-old returns from surgery Remove restraints one at a time and pro-
with elbow restraints in place. What nurs- vide range of motion exercises.
ing care should be included when caring
