a 3 year old comes to the clinic for a well child check up which respiratory assessment finding should the nurse expect this child to exhibit
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Nursing Elites

HESI LPN

HESI CAT Exam 2024

1. During a well-child check-up, what respiratory assessment finding should the nurse anticipate in a 3-year-old?

Correct answer: A

Rationale: A resting respiratory rate of 40 breaths per minute is within the expected range for a 3-year-old child. This is considered normal in this age group as their respiratory rate is generally higher compared to adults. Bronchovesicular breath sounds in the peripheral lung fields are not an expected finding in a 3-year-old. Retractions in the intercostal spaces with each inspiration indicate increased work of breathing and are abnormal. High-pitched whistling sounds over the bronchi are characteristic of wheezing, which is not typically expected in a healthy 3-year-old during a routine check-up.

2. After undergoing an uncomplicated gastric bypass surgery, a client is experiencing difficulty managing their diet. What dietary instruction is most important for the nurse to explain to the client?

Correct answer: A

Rationale: The correct answer is A. Thoroughly chewing food is crucial for clients who have undergone gastric bypass surgery to aid in digestion and prevent complications. Proper chewing helps break down food into smaller particles, making it easier for the digestive system to process. This instruction is essential to prevent issues such as food blockages or inadequate nutrient absorption. Choices B and C are also important for post-gastric bypass clients to maintain proper nutrition and hydration, but they are not as critical as ensuring thorough chewing. Choice D addresses dietary concerns but is not as immediately crucial as ensuring the client chews food properly to support digestion and prevent complications.

3. A 20-year-old male client is diagnosed with Ewing’s sarcoma following an examination for a knee injury. Which instruction is most important for the nurse to provide the client?

Correct answer: D

Rationale: The most crucial instruction for the nurse to provide the client is to seek treatment for the sarcoma immediately. Ewing's sarcoma is a type of cancer that necessitates prompt and aggressive treatment for the best possible outcome. While managing pain (Choice A) and monitoring swelling (Choice B) are important, addressing the underlying sarcoma is the priority. Instructing the client to avoid weight-bearing (Choice C) is not directly related to the treatment of Ewing's sarcoma and may not be the most critical instruction at this point.

4. A client has a blood glucose level of 70 mg/dl and reports feeling shaky and weak. What is the best initial action by the nurse?

Correct answer: B

Rationale: Administering 15 grams of a fast-acting carbohydrate is the best initial action to address hypoglycemia symptoms promptly by raising blood glucose levels. This intervention is crucial to prevent further deterioration in the client's condition. Obtaining a fingerstick glucose reading is important but may delay treatment. Performing a quick assessment of the client's neuro status is secondary to addressing the immediate low blood glucose levels. Providing a glass of milk is not the recommended first-line treatment for hypoglycemia; fast-acting carbohydrates are preferred to rapidly increase blood sugar levels.

5. The healthcare provider prescribes lidocaine (Lidoject-1) 100 mg IV push for ventricular tachycardia for an unconscious client. What is the nurse's priority intervention?

Correct answer: B

Rationale: The priority intervention for the nurse is to assess the client's neurological status q15 min. This is crucial to monitor for potential side effects of lidocaine, especially its neurotoxic effects. While measuring the client's cardiac output and collecting a blood specimen for serum potassium are important assessments, assessing the neurological status is the priority when administering lidocaine. Infusing lidocaine at a specific rate should follow the initial assessment of the client's neurological status to ensure safety.

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