HESI LPN
Pediatric HESI Test Bank
1. What is an essential nursing action when caring for a young child with severe diarrhea?
- A. Maintain the IV.
- B. Take daily weights.
- C. Replace the lost calories.
- D. Promote perianal skin integrity.
Correct answer: D
Rationale: Promoting perianal skin integrity is crucial when caring for a young child with severe diarrhea as it helps prevent skin breakdown from the irritation caused by frequent stooling. Maintaining the IV (Choice A) may be necessary but is not directly related to managing perianal skin integrity. Taking daily weights (Choice B) is important for monitoring fluid status but not the priority when addressing perianal skin integrity. While replacing lost calories (Choice C) is essential, promoting perianal skin integrity takes precedence in preventing complications associated with skin breakdown.
2. When changing the client's dressing, which observation should the nurse report to the client's surgeon for a client recovering from an appendectomy for a ruptured appendix with a surgical wound healing by secondary intention?
- A. A halo of erythema on the surrounding skin
- B. Presence of serous drainage
- C. Edema around the wound
- D. Absence of granulation tissue
Correct answer: A
Rationale: A halo of erythema on the surrounding skin may indicate an infection or inflammation of the wound site, which is critical to report to the surgeon. Erythema, redness, and warmth are signs of inflammation that could potentially be a sign of an infected wound. Serous drainage is a common and expected finding in healing wounds, indicating a normal healing process. Edema around the wound might be expected due to the body's response to tissue injury. The absence of granulation tissue in a wound healing by secondary intention may not be an immediate concern as it forms during the later stages of wound healing.
3. What instruction should the nurse include in the teaching plan for a client prescribed ranitidine for a peptic ulcer?
- A. Take this medication in the morning before breakfast.
- B. Take this medication with meals.
- C. Avoid taking this medication with antacids.
- D. Take this medication at bedtime.
Correct answer: A
Rationale: The correct instruction for a client prescribed ranitidine for a peptic ulcer is to take the medication in the morning before breakfast. This timing helps reduce stomach acid production throughout the day, providing optimal therapeutic effects. Option B is incorrect because taking ranitidine with meals is not the recommended timing. Option C is incorrect as there is no specific contraindication against taking ranitidine with antacids. Option D is incorrect as the medication should not be taken at bedtime but rather in the morning before breakfast.
4. A key component of primary prevention strategies is:
- A. aggressive interventions
- B. detection
- C. culture
- D. education
Correct answer: D
Rationale: The correct answer is 'D: education.' Education plays a vital role in primary prevention strategies by empowering individuals with knowledge and skills to prevent the onset of diseases. Through education, people can make informed decisions about their health, adopt healthy behaviors, and engage in preventive measures. Choice A, 'aggressive interventions,' is incorrect as primary prevention focuses on proactive measures to avoid the development of diseases rather than aggressive reactive interventions. Choice B, 'detection,' is more aligned with secondary prevention, which involves early identification of diseases. Choice C, 'culture,' while important in shaping health behaviors, is not a key component specifically in primary prevention strategies.
5. A 6-year-old with muscular dystrophy was recently injured falling out of bed at home. What intervention should the nurse suggest to prevent further injury?
- A. Recommend raising the bed's side rails when a caregiver is not present.
- B. Suggest a caregiver be present continuously to prevent falls from bed.
- C. Encourage the use of loose restraints while in bed.
- D. Recommend raising the bed's side rails throughout the day and night.
Correct answer: A
Rationale: In this scenario, the most appropriate intervention to prevent further injury is to raise the bed's side rails when a caregiver is not present. This measure helps in preventing falls without the need for constant supervision. Choice B is not practical as continuous caregiver presence may not always be feasible. Choice C is unsafe as loose restraints can pose a strangulation risk. Choice D does not address the need for intervention when a caregiver is absent, potentially leading to an increased risk of falls.