EDIATRICS - HESI PRACTICE EXAM
The nurse is giving preoperative instructions to a 14-year old female client who is
scheduled for surgery to correct a
... [Show More] spinal curvature. Which statement by the client
best demonstrates that learning has taken place?
A. I will read all the literature you gave me before surgery.
B. I have had surgery before when I broke my wrist in a bike accident, so I know
what to expect.
C. All the things people have told me will help me take care of my back.
D. I understand that I will be in a body cast and I will show you how you taught
me to turn.
(ANS- D. I understand that I will be in a body cast and I will show you how you
taught me to turn.
Outcome of learning is best demonstrated when the client not only verbalizes an
understanding, but also can provide a return demonstration. A 14-year old may or
may not follow through with reading material and there is no way of measuring
that way of learning. Have a previous surgery may help the client understand the
surgical process, but wrist surgery is very different from spinal surgery and
emergency surgery is different than elective surgery. In (C), the client may be
saying what the nurse wants to hear, without expressing any real understanding of
what to do after surgery.
To take the vital signs of a 4-month old child, which order will give the most
accurate results?
A. Respiratory rate, heart rate, then rectal temperature
B. Heart rate, rectal temperature, then respiratory rate.
C. Rectal temperature, heart rate, then respiratory rate
D. Rectal temperature, respiratory rate, then heart rate
(ANS- A. Respiratory rate, heart rate, then rectal temperature
The respiratory rate should be taken first in infants, since touching them or
performing unpleasant procedures usually makes them cry, elevating the heart rate
and making respirations difficult to count. Rectal temperature is the most invasive
procedure, and is mot likely to precipitate crying, so should be done last.
During routine screening at a school clinic, an otoscope examination of a child's
ear reveals a tympanic membrane that is pearly gray, slightly bulging, and not
movable. What action should the nurse take next?
A. No action required, as this is an expected finding for a school-aged child
B. Ask the child if he/she has had a cold, runny nose, or any ear pain lately.
C. Send a note home advising the parents to have the child evaluated by a
healthcare provider as soon as possible.
d. Call the parents and have them take the child home from school for the rest of
the day.
(ANS- B. Ask the child if he/she has had a cold, runny nose, or any ear pain lately.
More information is needed to interpret these findings. The tympanic membrane is
normally pearly gray, not bulging, and moves when the client blows against
resistance or a small puff of air is blown into the ear canal. Since this child's
findings are not completely normal, further assessment of history and related signs
and symptoms is indicated for accurate interpretation of the findings. (A), (C), and
(D) are inappropriate actions based on the data obtained from the otoscope
examination. [Show Less]