during a follow up clinical visit a mother tells the nurse that her 5 month old son who had surgical correction for tetralogy of fallot has rapid brea
Logo

Nursing Elites

HESI RN

Pediatric HESI Quizlet

1. During a follow-up clinical visit, a mother tells the nurse that her 5-month-old son, who had surgical correction for tetralogy of Fallot, has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held, and his growth is in the expected range. Which intervention should the nurse implement?

Correct answer: B

Rationale: Auscultating the heart and lungs while the infant is held is the most appropriate intervention to assess his current condition. This action allows the nurse to gather important information regarding the cardiovascular and respiratory status of the infant, which is crucial in evaluating his post-surgical recovery and overall well-being. Option A is incorrect as stimulating the infant to cry intentionally is not necessary and could cause distress. Option C is incorrect as the infant's growth is within the expected range, indicating no signs of failure to thrive. Option D is incorrect as obtaining a 12-lead electrocardiogram is not the initial intervention needed in this situation; assessing the heart and lungs through auscultation is more immediate and informative.

2. After reinforcing information on treating a sprained ankle, what statement by the adolescent indicates to the practical nurse that further instruction is needed?

Correct answer: C

Rationale: The correct answer is C. Applying warm compresses to a sprained ankle within the first 24 hours is incorrect as it can increase swelling and inflammation. Instead, cold compresses are recommended to help reduce swelling and pain. Option A, keeping the leg elevated, helps in reducing swelling. Option B, wrapping the ankle in an elastic bandage, provides support. Option D, using an ice pack in intervals, is effective in reducing swelling and pain. Therefore, the statement about applying warm compresses indicates the need for further instruction.

3. The nurse is assessing a 4-year-old child who is brought to the clinic for a routine checkup. The child’s parent reports that the child has been more irritable and less active over the past week. The nurse notes a petechial rash on the child’s trunk and extremities. What should the nurse do first?

Correct answer: D

Rationale: In this scenario, the child's presentation with irritability, decreased activity, and a petechial rash raises concern for a serious condition like meningitis. Petechial rash can be indicative of meningitis or other critical illnesses. Therefore, the nurse's priority should be to notify the healthcare provider immediately to ensure prompt evaluation and appropriate management. Asking about recent exposure to contagious diseases may be relevant later but is not the most urgent action. Reviewing the child's immunization record and measuring the temperature can provide valuable information but should not take precedence over the need to address the potential serious condition indicated by the petechial rash.

4. A child with Graves' disease who is taking propranolol (Inderal) is seen in the clinic. The nurse should monitor the child for which therapeutic response?

Correct answer: B

Rationale: When a child with Graves' disease is prescribed propranolol (Inderal), the nurse should monitor for a decreased heart rate as a therapeutic response. Propranolol is a beta-blocker that acts to slow down the heart rate, which is beneficial in managing the symptoms of Graves' disease, such as tachycardia and other cardiovascular manifestations. Choices A, C, and D are incorrect because propranolol is not typically associated with increased weight gain, reduced headaches, or diminished fatigue as its primary therapeutic effect in this context.

5. The healthcare provider is preparing to administer digoxin (Lanoxin) to a 6-month-old infant with heart failure. The healthcare provider notes that the infant’s heart rate is 90 beats per minute. What should the healthcare provider do next?

Correct answer: B

Rationale: In this scenario, the correct action is to hold the medication and notify the healthcare provider. Digoxin should be withheld if the infant’s heart rate is below 100 beats per minute. Administering digoxin in this situation can further slow down the heart rate in infants with heart failure, leading to potential adverse effects. Reassessing the heart rate in 30 minutes is not the best immediate action to take, as prompt notification and withholding of the medication are crucial. Administering the medication as prescribed or giving half the dose can exacerbate the situation by potentially further lowering the heart rate.

Similar Questions

A 2-year-old is admitted to the hospital with possible encephalitis, and a lumbar puncture is scheduled. Which information should the nurse provide this child concerning the procedure?
Which assessment finding should the healthcare provider identify as most concerning in a child with acute glomerulonephritis?
When should a mother introduce solid foods to her 4-month-old baby girl? The mother states, 'My mother says I should put rice cereal in the baby's bottle now.' The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?
When assessing a child with suspected meningitis, which finding is a characteristic sign of meningitis?
The parents of a 10-year-old child with newly diagnosed type 1 diabetes are being taught by the nurse about managing their child’s condition. Which statement by the parents indicates they need further teaching?

Access More Features

HESI RN Basic
$89/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses