HESI RN
Pediatric HESI
1. A 4-year-old child with a history of frequent ear infections is brought to the clinic by the parents who are concerned about the child’s hearing. What is the nurse’s priority action?
- A. Perform a hearing test
- B. Inspect the child’s ears for drainage
- C. Refer the child to an audiologist
- D. Ask the parents about the child’s speech development
Correct answer: B
Rationale: The nurse's priority action should be to inspect the child's ears for drainage. This immediate assessment can provide valuable information about the presence of infection or fluid accumulation, which can directly impact the child's hearing. By identifying any signs of drainage, the nurse can promptly address any current issues affecting the child's ear health and hearing abilities. Performing a hearing test (Choice A) may be necessary but should follow the initial assessment of the ears. Referring the child to an audiologist (Choice C) can be considered later based on the findings. Asking about speech development (Choice D) is important but not the immediate priority compared to assessing for current ear issues.
2. Which information is a priority for the RN to reinforce to an older client after intravenous pyelography?
- A. Eat a light diet for the remainder of the day
- B. Rest for the next 24 hours as the preparation and the test are tiring
- C. Drink at least 1 8-ounce glass of fluid every waking hour for the next 2 days
- D. Measure the urine output for the next day and promptly notify the healthcare provider if it decreases
Correct answer: D
Rationale: After intravenous pyelography, it is crucial for the client to measure urine output in the next day to monitor for any potential complications, such as kidney issues. Promptly notifying the healthcare provider in case of decreased urine output is essential for timely intervention. While rest and hydration are important post-procedure, monitoring urine output takes precedence due to its direct correlation with potential complications.
3. Assessment findings of a 3-hour-old newborn include: axillary temperature of 97.7°F, heart rate of 140 beats/minute with a soft murmur, and irregular respiratory rate at 42 breaths/min. Based on these findings, what action should the nurse implement?
- A. Place a pulse oximeter on the heel
- B. Swaddle the infant in a warm blanket
- C. Record the findings on the flow sheet
- D. Check the vital signs in 15 minutes
Correct answer: C
Rationale: The correct answer is to record the findings on the flow sheet. These assessment findings are within normal limits for a 3-hour-old newborn. The axillary temperature of 97.7°F, heart rate of 140 beats/minute with a soft murmur, and irregular respiratory rate of 42 breaths/min are all expected in a newborn. No immediate intervention is needed, so the nurse should document these normal findings for future reference. Placing a pulse oximeter on the heel or swaddling the infant in a warm blanket is not indicated as the vital signs are within normal limits. Checking the vital signs in 15 minutes is unnecessary since the current findings are normal.
4. A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. What action should the nurse implement?
- A. Determine if the client has also experienced breast tenderness and weight gain.
- B. Encourage the client to begin a regular, daily program of walking and exercise.
- C. Advise the client to notify the healthcare provider for immediate medical attention.
- D. Tell the client to stop taking the medication for a week to see if symptoms subside.
Correct answer: C
Rationale: Calf pain is indicative of thrombophlebitis, a serious, life-threatening complication associated with the use of oral contraceptives which requires further assessment and possibly immediate medical intervention.
5. The healthcare provider prescribes exenatide (Byetta) for a client with type 1 diabetes mellitus who takes insulin. What is the appropriate intervention for the nurse?
- A. Administer the medication within 60 minutes before the morning and evening meal.
- B. Withhold the medication and question the prescription with the healthcare provider.
- C. Monitor the client for gastrointestinal side effects after administration of the medication.
- D. Withdraw the insulin from the Penlet into an insulin syringe to prepare for administration.
Correct answer: B
Rationale: Exenatide (Byetta) is specifically indicated for the treatment of type 2 diabetes mellitus and is not recommended for clients with type 1 diabetes mellitus who are taking insulin. Choice A is incorrect because exenatide should not be administered to a client with type 1 diabetes mellitus who takes insulin. Choice C is not the most appropriate initial action when the prescription is not suitable for the client. Choice D is unrelated to the administration of exenatide. Therefore, the appropriate intervention for the nurse is to withhold the medication and question the prescription with the healthcare provider to ensure the safety and appropriateness of the treatment plan for the client.