HESI RN
Pediatric HESI
1. What action should the nurse implement after the infusion is complete for a 16-year-old with acute myelocytic leukemia receiving chemotherapy via an implanted medication port at the outpatient oncology clinic?
- A. Administer Zofran
- B. Obtain blood samples for RBCs, WBCs, and platelets
- C. Flush the mediport with saline and heparin solution
- D. Initiate an infusion of normal saline
Correct answer: C
Rationale: After completing the chemotherapy infusion via the implanted medication port, the nurse should flush the mediport with saline and heparin solution. This action helps prevent clot formation in the port, ensuring its patency for future use and reducing the risk of complications associated with catheter occlusion. Administering Zofran (Choice A) is used for managing chemotherapy-induced nausea and vomiting, not for post-infusion care. Obtaining blood samples for RBCs, WBCs, and platelets (Choice B) is important for monitoring the patient's blood count but is not the immediate post-infusion priority. Initiating an infusion of normal saline (Choice D) is not necessary after completing the chemotherapy infusion.
2. Expanded access to family planning is facilitated by the use of:
- A. The private sector and social marketing
- B. Community-based programs
- C. Information, Education, and Communication
- D. All of the above
Correct answer: D
Rationale: Expanded access to family planning is achieved through various means, including utilizing the private sector, employing social marketing strategies, implementing community-based programs, and emphasizing Information, Education, and Communication initiatives. Each of the options plays a crucial role in enhancing access to family planning services. Therefore, the correct answer is 'All of the above.' Option A focuses on involving the private sector and social marketing, which are essential components. Option B emphasizes community-based programs, which are another key aspect. Option C highlights the significance of Information, Education, and Communication in promoting family planning. As all these strategies are integral to expanding access to family planning, the most comprehensive answer is 'All of the above.'
3. A client is receiving desmopressin acetate (DDAVP), and a healthcare provider is monitoring for adverse effects. Which of the following indicates the presence of an adverse effect?
- A. Insomnia
- B. Drowsiness
- C. Weight loss
- D. Increased urination
Correct answer: B
Rationale: Drowsiness can be a sign of water intoxication or hyponatremia, which are potential adverse effects of desmopressin acetate (DDAVP). It is crucial to monitor for this symptom and promptly address it to prevent complications.
4. A female client with obsessive-compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving and reports her findings to the RN at bedtime. What action should the nurse implement?
- A. Explain to the client that her behavior invades the rights of the nursing staff.
- B. Ask the client to explain why she is keeping a detailed record of her nursing care.
- C. Teach the client strategies to control her obsessive-compulsive behavior.
- D. Encourage the client to express her feelings regarding the upcoming procedure.
Correct answer: B
Rationale: Asking the client to explain why she is keeping a detailed record of her nursing care is the most appropriate action for the nurse to take in this situation. Understanding the client’s motivations for keeping detailed records can provide insight into her obsessive-compulsive behaviors and help manage them effectively. This approach allows for a non-confrontational exploration of the behavior. Choice A is incorrect because it may be perceived as confrontational and does not address the underlying reasons for the behavior. Choice C is incorrect because teaching strategies to control behavior should come after understanding the client's motives. Choice D is incorrect as it does not directly address the behavior of keeping detailed records, which is the immediate concern that needs to be addressed.
5. A 16-year-old adolescent with cystic fibrosis is admitted to the hospital with a respiratory infection. The nurse is teaching the adolescent about the importance of airway clearance techniques. Which statement by the adolescent indicates a need for further teaching?
- A. I should do my airway clearance exercises every day.
- B. I don’t need to do my airway clearance exercises if I feel okay.
- C. Airway clearance helps prevent mucus buildup in my lungs.
- D. I should continue my airway clearance routine even when I’m not sick.
Correct answer: B
Rationale: The correct answer is B. Airway clearance exercises are essential for individuals with cystic fibrosis to prevent mucus buildup in their lungs. It is crucial to perform these exercises regularly, even when feeling well, to maintain lung health and prevent complications. Choice A is correct as doing airway clearance exercises daily is necessary. Choice C is also accurate as airway clearance does indeed help prevent mucus buildup. Choice D is correct as it is important to continue the airway clearance routine even when not sick to maintain lung health. Choice B is incorrect because stating that airway clearance exercises are unnecessary when feeling okay demonstrates a misunderstanding of the importance of consistent airway clearance in cystic fibrosis management.