HESI RN
HESI Practice Test Pediatrics
1. The caregiver is caring for a 2-month-old infant with a diagnosis of bronchiolitis. Which assessment finding would be most concerning to the caregiver?
- A. Nasal flaring and grunting
- B. Coughing and wheezing
- C. Poor feeding and irritability
- D. Increased respiratory rate
Correct answer: A
Rationale: Nasal flaring and grunting are indicative of respiratory distress, suggesting the infant is having difficulty breathing. This finding requires immediate attention as it signifies a more severe respiratory compromise compared to the other symptoms listed.
2. A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling 'very tired'. Which nursing intervention is most important for the nurse to implement?
- A. Measure vital signs
- B. Auscultate breath sounds
- C. Palpate the abdomen
- D. Observe the skin for bruising
Correct answer: A
Rationale: The correct answer is to measure vital signs. Abrupt withdrawal of exogenous corticosteroids can precipitate adrenal insufficiency, potentially leading to shock. Monitoring vital signs is crucial in identifying any signs of adrenal insufficiency, such as hypotension or tachycardia. Auscultating breath sounds (choice B) may be important in other situations, such as respiratory conditions, but it is not the priority in this case. Palpating the abdomen (choice C) and observing the skin for bruising (choice D) are not directly related to the potential complications of corticosteroid withdrawal and adrenal insufficiency.
3. A client with hyperlipidemia is prescribed atorvastatin (Lipitor). Which instruction should the nurse include in the teaching plan?
- A. Take the medication in the morning.
- B. Avoid consuming grapefruit juice.
- C. Increase your intake of dairy products.
- D. Take the medication with food.
Correct answer: B
Rationale: The correct instruction for the nurse to include in the teaching plan is to advise the client to avoid consuming grapefruit juice. Grapefruit juice can increase the risk of atorvastatin (Lipitor) toxicity by inhibiting its metabolism. Atorvastatin is typically taken in the evening as cholesterol synthesis occurs at night. Increasing dairy intake is not specifically recommended for atorvastatin therapy, and the medication can be taken with or without food.
4. A client with cirrhosis is experiencing ascites and peripheral edema. What is the nurse's priority intervention?
- A. Administer furosemide as prescribed.
- B. Administer albumin to increase oncotic pressure.
- C. Elevate the client's legs to reduce swelling.
- D. Administer a sodium-restricted diet.
Correct answer: A
Rationale: The correct answer is A: Administer furosemide as prescribed. Administering furosemide, a loop diuretic, is the priority intervention in a client with cirrhosis experiencing ascites and peripheral edema. Furosemide helps promote diuresis and reduce fluid buildup in the body. Choice B, administering albumin to increase oncotic pressure, may be beneficial in some cases but is not the priority intervention for immediate fluid removal. Elevating the client's legs (Choice C) and administering a sodium-restricted diet (Choice D) are important aspects of managing edema and ascites but are not the priority interventions in this situation.
5. A female client’s significant other has been at her bedside providing reassurances and support for the past 3 days, as desired by the client. The client’s estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement?
- A. Obtain a prescription from the healthcare provider regarding visitation privileges
- B. Request a consultation with the ethics committee for resolution of the situation
- C. Encourage the client to speak with her husband regarding his disruptive behavior
- D. Communicate the client’s wishes to all members of the multidisciplinary team
Correct answer: B
Rationale: In a situation where a client's estranged husband demands to restrict the visitation of the significant other, it is essential to prioritize the client's wishes while addressing the conflict. Requesting a consultation with the ethics committee is appropriate as it allows for a comprehensive and impartial resolution, ensuring the client's autonomy and well-being are upheld. Option A is incorrect because visitation privileges are not solely determined by a healthcare provider's prescription in this scenario. Option C may not be appropriate as it puts the client in a potentially uncomfortable or unsafe position. Option D, while important, does not directly address the conflict between the estranged husband and the significant other.