the nurse is caring for a 3 year old child who has been recently diagnosed with cystic fibrosis which discharge instruction by the nurse is most impor
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HESI RN

Pediatric HESI Quizlet

1. The nurse is caring for a 3-year-old child who has been recently diagnosed with cystic fibrosis. Which discharge instruction by the nurse is most important to promote pulmonary function?

Correct answer: B

Rationale: In cystic fibrosis, thick mucus obstructs the airways, making it difficult to clear from the lungs. Cough suppressants can help reduce the discomfort associated with persistent coughing, allowing the child to cough more effectively to clear the mucus, thus promoting pulmonary function. Chest physiotherapy, not exercise, helps mobilize the mucus. Oxygen therapy may be needed but is not the most important for promoting pulmonary function in this case.

2. The nurse provides information about the human papillomavirus (HPV) vaccine to the mother of a 14-year-old adolescent who came to the clinic this morning complaining of menstrual cramping. Which explanation should the nurse provide to support administering the HPV vaccine to the adolescent at this visit?

Correct answer: D

Rationale: Administering the HPV vaccine helps establish immunity before potential exposure to the virus, reducing the risk of HPV infection and subsequent development of cervical cancer. It is recommended to vaccinate adolescents before they become sexually active for maximum effectiveness. Choice A is incorrect because while protective barriers can reduce the risk, they do not prevent all strains of HPV. Choice B is incorrect and judgmental as it assumes dishonesty without providing relevant information about HPV vaccination. Choice C is incorrect as it downplays the importance of vaccination by suggesting that not all strains are necessary to cover, which is not the case in preventing HPV-related diseases.

3. A 14-year-old adolescent with a history of substance abuse is brought to the emergency department by the parents, who suspect that the adolescent has relapsed. What is the nurse’s priority action?

Correct answer: A

Rationale: In this scenario, the nurse's priority action should be to obtain a urine sample for toxicology screening. This step is crucial in identifying the substances involved in the relapse, which will guide appropriate treatment strategies. By knowing the specific substances, healthcare providers can tailor treatment plans effectively. Establishing a therapeutic relationship and discussing treatment options come after obtaining necessary diagnostic information to ensure a comprehensive care plan. Administering a medication to reverse substance effects is not the initial priority; identification of the substances through toxicology screening should precede any treatment intervention.

4. 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?

Correct answer: A

Rationale: Children, especially young ones, benefit from knowing what position they will be in during a procedure as it helps them understand and feel more in control. Describing the side-lying, knees-to-chest position can reduce anxiety and promote cooperation during the lumbar puncture. Choice B is incorrect because the question is about preparing the child for the procedure, not about pre-procedure fasting requirements. Choice C is incorrect because there may be restrictions on activity after the procedure. Choice D is incorrect because mentioning loud clicking noises may increase the child's anxiety and fear.

5. The healthcare provider finds a 6-month-old infant unresponsive and calls for help. After opening the airway and finding the infant is still not breathing, which action should the provider take?

Correct answer: C

Rationale: In pediatric basic life support, for an unresponsive infant who is not breathing normally, the correct action is to give two breaths that make the chest rise. This helps provide oxygen to the infant's body and is a crucial step in resuscitation efforts for infants in distress. Choices A, B, and D are incorrect. Palpating the femoral pulse or feeling the carotid pulse is not indicated in this scenario where the infant is unresponsive and not breathing. Delivering cycles of chest compressions and breaths is not the immediate action to take; the priority is to provide two breaths to help with oxygenation.

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