HESI LPN
Pediatric HESI Test Bank
1. The nurse is caring for a 3-day-old girl with Down syndrome whose mother had no prenatal care. What is the priority nursing diagnosis?
- A. Imbalanced nutrition, less than body requirements related to the effects of hypotonia
- B. Deficient knowledge related to the presence of a genetic disorder
- C. Delayed growth and development related to a cognitive impairment
- D. Impaired physical mobility related to poor muscle tone
Correct answer: A
Rationale: The priority nursing diagnosis for a 3-day-old girl with Down syndrome, whose mother had no prenatal care, is imbalanced nutrition, less than body requirements related to the effects of hypotonia. Newborns with Down syndrome often experience feeding difficulties due to hypotonia, which can lead to inadequate nutrition intake. Option B is incorrect because at this age, the infant is not capable of having knowledge deficits related to a genetic disorder. Option C is incorrect as delayed growth and development are not the immediate priority in this scenario. Option D is incorrect as impaired physical mobility is not typically a priority concern for a newborn with Down syndrome.
2. A 7-month-old girl is to be catheterized to obtain a sterile urine specimen. One of the infant’s parents expresses fear that this procedure may traumatize the baby psychologically. How should the nurse provide reassurance?
- A. The fear is justified and the nurse should obtain a “clean catch” specimen.
- B. Parents have a right to refuse the catheterization and the concerns are realistic.
- C. Although the concern is appropriate, the need for a sterile specimen is the priority.
- D. The procedure is uncomfortable, but there should not be a damaging long-term effect.
Correct answer: D
Rationale: While catheterization can be uncomfortable, it does not typically result in long-term psychological harm, and obtaining a sterile specimen is important for accurate diagnosis.
3. A client with amphetamine toxicity and sensory overload is being cared for by a nurse. Which intervention should the nurse implement?
- A. Immediately conduct a thorough assessment.
- B. Encourage visitors to distract the client.
- C. Provide a private room and limit stimulation.
- D. Speak softly to the client.
Correct answer: C
Rationale: The most appropriate intervention for a client with amphetamine toxicity and sensory overload is to provide a private room and limit stimulation. This approach helps reduce external stimuli, which can exacerbate sensory overload, and creates a calming environment for the client. Encouraging visitors to distract the client may worsen sensory overload by adding more stimulation. Speaking softly, rather than at a higher volume, is more suitable to help maintain a calm environment. Therefore, the correct choice is to provide a private room and limit stimulation (option C) in this scenario.
4. What should the nurse do to complete a focused assessment for a female client with inflamed and painful hemorrhoids?
- A. Determine if the client uses any over-the-counter preparations for hemorrhoids
- B. Place the client in a standing position, leaning over the exam bed for inspection
- C. Position the client in the left lateral position to inspect the perineal area for fissures or sacs
- D. Ask the client how long she has experienced discomfort related to hemorrhoids
Correct answer: D
Rationale: Asking the client about the duration of discomfort related to hemorrhoids is the best intervention to implement for a focused assessment. This information provides important context for assessing the severity and chronicity of the condition, which is crucial for developing an appropriate care plan. Choices A, B, and C do not directly address the need to gather information about the duration of symptoms, which is essential for understanding the client's condition.
5. A nurse is receiving a verbal prescription from the provider for a client who is experiencing increased pain. The nurse should transcribe which of the following prescriptions in the client's medical record?
- A. Morphine sulfate 10 mg IV q 4 IV prn for pain
- B. MS 10 mg IV every 4 8 prn for pain
- C. MSO4 10 mg IVP q 4 8 prn for pain
- D. Morphine sulfate 10.0 mg every 4 hours IV prn for pain
Correct answer: A
Rationale: The correct transcription is 'Morphine sulfate 10 mg IV q 4 IV prn for pain.' In choice A, 'Morphine sulfate 10 mg IV q 4 IV prn for pain' correctly indicates the medication, route (IV), frequency (every 4 hours), and administration as needed for pain control. Choice B is incorrect as 'MS' is not a standard abbreviation for Morphine Sulfate, and the frequency 'every 4 8' is not a valid time interval. Choice C is incorrect as 'MSO4' is not the standard abbreviation for Morphine Sulfate, and 'IVP' is not the standard route abbreviation for intravenous. Choice D is incorrect as it lacks clarity with '10.0 mg' instead of '10 mg,' and the frequency is given as 'every 4 hours' without specifying the route of administration.