HESI LPN
Pediatric HESI Test Bank
1. When caring for a child diagnosed with cystic fibrosis, what is the priority nursing intervention?
- A. Administering pancreatic enzymes
- B. Providing respiratory therapy
- C. Encouraging physical activity
- D. Encouraging frequent handwashing
Correct answer: A
Rationale: The priority nursing intervention when caring for a child with cystic fibrosis is administering pancreatic enzymes. Cystic fibrosis is a genetic disorder that affects the digestive and respiratory systems. Administering pancreatic enzymes is crucial in aiding digestion as patients with cystic fibrosis often have pancreatic insufficiency. While providing respiratory therapy and encouraging physical activity are important aspects of care for individuals with cystic fibrosis, administering pancreatic enzymes takes precedence in addressing the malabsorption issues associated with the condition. Encouraging frequent handwashing is also essential in infection control, but it is not the priority intervention specifically related to managing cystic fibrosis.
2. A client is being treated for dehydration. Which clinical finding would indicate that treatment is effective?
- A. Dry mucous membranes
- B. Increased urine output
- C. Tachycardia
- D. Hypotension
Correct answer: B
Rationale: The correct answer is B: Increased urine output. When a client is being treated for dehydration, increased urine output is a positive indication that the treatment is effective. This signifies that the body is beginning to rehydrate and eliminate excess fluid. Choices A, C, and D are incorrect because dry mucous membranes, tachycardia, and hypotension are all associated with dehydration and would not be signs of effective treatment.
3. A client with chronic kidney disease has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent?
- A. Distended, tortuous veins in the left hand
- B. The left radial pulse is 2+ bounding
- C. Auscultation of a thrill on the left forearm
- D. Assessment of a bruit on the left forearm
Correct answer: C
Rationale: Auscultation of a thrill on the left forearm is the correct observation indicating that the AV fistula is patent. A thrill is a palpable vibration or buzzing sensation felt over the fistula, indicating the presence of blood flow. Choices A, B, and D do not directly assess the patency of the fistula. Distended, tortuous veins in the left hand may indicate venous hypertension; a bounding radial pulse could suggest increased blood flow through an artery, but it does not confirm fistula patency; assessment of a bruit indicates turbulent blood flow, but it does not confirm patency.
4. What intervention is recommended for a child with severe dehydration?
- A. Oral rehydration therapy
- B. Intravenous fluid replacement
- C. High-protein diet
- D. Increased physical activity
Correct answer: B
Rationale: Intravenous fluid replacement is the recommended intervention for a child with severe dehydration because it allows for rapid restoration of fluid and electrolyte balance. In severe cases, oral rehydration therapy (Choice A) may not be tolerated due to the child's condition. A high-protein diet (Choice C) is not the primary intervention and does not address the immediate fluid and electrolyte imbalance. Increased physical activity (Choice D) is contraindicated in severe dehydration as it can exacerbate fluid loss, making intravenous fluid replacement the most suitable choice for prompt correction of the severe dehydration.
5. The nurse enters the room of a client who is awaiting surgery for appendicitis. The unlicensed assistive personnel (UAP) has helped the client to a position of comfort with the right leg flexed and has applied a heating pad to the client’s abdomen to relieve the client’s pain. Which action should the nurse implement first?
- A. Remove the heating pad.
- B. Reposition the client’s right leg.
- C. Monitor for signs of inflammation.
- D. Assess the client’s pain level.
Correct answer: A
Rationale: The correct action for the nurse to implement first is to remove the heating pad. Heating pads should not be used for suspected appendicitis as they can mask symptoms and potentially worsen inflammation. Choice B is not the priority as the position of comfort chosen by the UAP may be appropriate. Monitoring for signs of inflammation (Choice C) is important but not the initial action to address the immediate issue of the heating pad. Assessing the client's pain level (Choice D) can be done after removing the heating pad to evaluate the effectiveness of pain relief measures.