HESI RN
Pediatric HESI
1. What intervention should the nurse implement first for a male toddler brought to the emergency center approximately three hours after swallowing tablets from his grandmother's bottle of digoxin (Lanoxin)?
- A. Administer activated charcoal
- B. Prepare gastric lavage
- C. Obtain a 12-lead electrocardiogram
- D. Give IV digoxin immune fab (Digibind)
Correct answer: A
Rationale: Administering activated charcoal is the priority intervention as it binds with digoxin, preventing further absorption in the gastrointestinal tract. This helps reduce the amount of digoxin available for systemic circulation and minimizes its toxic effects. Gastric lavage is no longer recommended due to potential complications and lack of evidence of efficacy. Obtaining an electrocardiogram may help assess the effects of digoxin toxicity, but it is not the initial priority. IV digoxin immune fab (Digibind) is used in severe cases of digoxin toxicity but is not the first-line intervention.
2. The heart rate for a 3-year-old with a congenital heart defect has steadily decreased over the last few hours; it is now 76 bpm, whereas the previous reading 4 hours ago was 110 bpm. Which additional finding should be reported immediately to a healthcare provider?
- A. Oxygen saturation of 94%.
- B. Respiratory rate of 25 breaths/minute.
- C. Urine output of 20 mL/hr.
- D. Blood pressure of 70/40.
Correct answer: D
Rationale: A significant drop in heart rate and blood pressure should be reported immediately as it may indicate worsening of the congenital heart defect. A decrease in blood pressure to 70/40 is a critical finding that suggests potential cardiovascular compromise and requires urgent attention to prevent further deterioration. Oxygen saturation, respiratory rate, and urine output are important parameters, but in this scenario, the alarming decrease in blood pressure is a more critical finding that necessitates immediate reporting to the healthcare provider.
3. What information should the nurse provide to parents of a 3-year-old boy with Duchenne muscular dystrophy who inquire about the disease and future children?
- A. This is an inherited X-linked recessive disorder, which primarily affects male children in the family
- B. The striated muscle groups of males can be impacted by a lack of the protein dystrophin in their mothers
- C. The male infant had a viral infection that went unnoticed and untreated so muscle damage was incurred
- D. Birth trauma with a breech vaginal birth causes damage to the spinal cord, thus weakening the muscles
Correct answer: A
Rationale: Duchenne muscular dystrophy is an X-linked recessive disorder caused by mutations in the DMD gene on the X chromosome. This disorder primarily affects males because they have one X chromosome, inherited from their mothers, who may be carriers of the mutated gene. Females have two X chromosomes, providing a protective effect as the normal gene on one X chromosome can compensate for the mutated gene on the other. Therefore, the nurse should explain to the parents that Duchenne muscular dystrophy is an inherited X-linked recessive disorder, which is why their son has the disease and why there is a risk of passing it on to future sons. Choice B is incorrect as it inaccurately implies that the lack of dystrophin in mothers impacts their sons' muscle groups. Choice C is incorrect as it suggests a viral infection caused the muscle damage, which is not the case with Duchenne muscular dystrophy. Choice D is incorrect as it attributes the muscle weakness to birth trauma instead of the genetic nature of the disorder.
4. When assessing a 10-year-old newly diagnosed with osteomyelitis, which information is most important for the nurse to obtain?
- A. Recent history of infection recurrences.
- B. Cultural heritage and beliefs.
- C. Family history of bone disorders.
- D. Increased fluid intake occurrences.
Correct answer: A
Rationale: In a 10-year-old with newly diagnosed osteomyelitis, the most important information for the nurse to obtain is the recent history of infection recurrences. This is crucial because osteomyelitis is an infection of the bone, and assessing for any recent recurrence of infections can help in determining the possible source of the osteomyelitis and guide the treatment plan accordingly. Choices B, C, and D are less relevant in the immediate assessment of a newly diagnosed case of osteomyelitis as they do not directly impact the current infection or treatment plan.
5. A child who weighs 25 kg is receiving IV ampicillin 300 mg/kg/24 hours in equally divided doses every 4 hours. How many milligrams should the nurse administer to the child for each dose?
- A. 1875 mg
- B. 625 mg
- C. 2000 mg
- D. 1500 mg
Correct answer: A
Rationale: To calculate the dose for each administration, multiply the child's weight (25 kg) by the dose (300 mg/kg/24 hours) and divide by the number of doses per day (6, as doses are every 4 hours). This gives us (25 kg * 300 mg/kg / 24 hours) / 6 doses = 1875 mg. Therefore, the nurse should administer 1875 mg for each dose. Choice B, 625 mg, is incorrect as it does not consider the correct calculation based on the weight and prescribed dose. Choice C, 2000 mg, is incorrect as it is not derived from the correct dosage calculation. Choice D, 1500 mg, is incorrect as it does not reflect the accurate dosage calculation based on the weight of the child and the prescribed dose.
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