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