HESI RN PEDIATRICS
1.The nurse is planning postoperative care for a child who has had a cleft lip repair.
What is the most important reason to
... [Show More] 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
Rationale:
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.
2. 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.
Rationale:
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.
3. 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 ambulation in the pre-operative period
Rationale:
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.
4. 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
Rationale:
A child with celiac disease is managed on a gluten-free diet, which eliminates food
products containing oats, wheat, rye, or barley.
5. 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.
Rationale:
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.
6. The nurse assigns an unlicensed assistive personnel (UAP) 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 UAP?
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.
Rationale:
All these are important measures to review with the UAP, 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.
7. The nurse is caring for a child with intussusception who is scheduled for a
barium enema prior to a surgical procedure. Which action should the nurse take
first?
A. Evacuate the bowel of impacted feces
B. Admnister magnesium sulfate
C. Place the child on a clear liquid diet
D. Assess the stool for white color
Rationale:
Intussusception, an invagination or telescoping of one portion of the intestine into
another, causes intestinal obstruction in children (usually occurs between 3 months
and 5 years of age). Nonsurgical treatment is attempted with hydrostatic pressure
created by barium instillation, which often reduces the area of bowel
intussusception. In preparation for a barium enema, the client should first be placed
on a clear liquid diet for the entire day; then magnesium sulfate is administered for
bowel evacuation. A barium enema is likely to cause option A. After the enema,
white stool may be seen as the body naturally removes any remaining barium. [Show Less]