HESI LPN
Pediatric HESI 2024
1. An infant is diagnosed with Hirschsprung disease. What nursing intervention is essential before surgery?
- A. Administering antibiotics
- B. Ensuring bowel rest
- C. Performing regular enemas
- D. Maintaining NPO status
Correct answer: D
Rationale: Maintaining NPO (nothing by mouth) status is essential before surgery for a patient with Hirschsprung disease to prevent aspiration. Administering antibiotics, ensuring bowel rest, and performing regular enemas are not the priority interventions before surgery for this condition. Administering antibiotics may be necessary in the postoperative period to prevent infection, ensuring bowel rest can be beneficial but is not the priority, and performing regular enemas is not typically recommended before surgery for Hirschsprung disease.
2. The nurse is assessing a child with a possible fracture. What would the nurse identify as the most reliable indicator?
- A. Lack of spontaneous movement
- B. Point tenderness
- C. Bruising
- D. Inability to bear weight
Correct answer: B
Rationale: Point tenderness is the most reliable indicator of a possible fracture in a child. It is a localized tenderness experienced when pressure is applied to a specific area, suggesting a potential fracture. This tenderness is considered more specific to a fracture than other symptoms such as lack of spontaneous movement, bruising, or inability to bear weight. Lack of spontaneous movement and inability to bear weight can be present in various musculoskeletal injuries, while bruising may not always be immediate or specific to a fracture.
3. The nurse is teaching a client about the healthy use of ego defense mechanisms. An appropriate goal for this client would be
- A. Reduce fear and protect self-esteem
- B. Minimize anxiety and delay apprehension
- C. Avoid conflict and leave unpleasant situations
- D. Increase independence and communicate more effectively
Correct answer: A
Rationale: The correct answer is A: 'Reduce fear and protect self-esteem.' When teaching a client about the healthy use of ego defense mechanisms, the goal is to help the individual manage emotions effectively without denying reality. Using defense mechanisms in a healthy way aims to reduce fear and protect self-esteem while still addressing underlying issues. Choices B, C, and D are incorrect because they do not focus on the core principles of using defense mechanisms in a healthy manner. Minimizing anxiety and delaying apprehension, avoiding conflict and leaving unpleasant situations, and increasing independence and communicating more effectively do not directly align with the goal of utilizing ego defense mechanisms in a constructive way.
4. A client with a terminal illness and approaching death has noisy respirations and is short of breath. Which of the following actions should the nurse take?
- A. Elevate the head of the client's bed
- B. Administer an opioid medication
- C. Perform oral suctioning
- D. Place the client in a prone position
Correct answer: A
Rationale: Elevating the head of the client's bed is the most appropriate action in this situation. It helps reduce noisy respirations and improves comfort for clients with terminal illnesses by facilitating better air exchange. Administering an opioid medication may not address the immediate issue of noisy respirations and shortness of breath caused by secretions in the airway. Performing oral suctioning without proper assessment and indication can be uncomfortable for the client and may not be necessary. Placing the client in a prone position can further compromise breathing and is not recommended for a client with respiratory distress.
5. What is an important consideration when administering medications to a child with hepatic dysfunction?
- A. Increased dosing intervals
- B. Adjustments in dosage due to altered metabolism
- C. Avoid all medications
- D. Use only topical medications
Correct answer: B
Rationale: When administering medications to a child with hepatic dysfunction, it is crucial to make adjustments in dosage due to altered metabolism. Hepatic dysfunction can affect the way medications are metabolized in the body, potentially leading to drug toxicity or reduced effectiveness. This is why adjusting the dosage is essential to ensure the medication is both safe and efficient. Choices A, C, and D are incorrect because increasing dosing intervals, avoiding all medications, or using only topical medications do not address the specific issue of altered drug metabolism in hepatic dysfunction.