what is an important nursing responsibility when a dysrhythmia is suspected
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Nursing Elites

HESI LPN

Pediatrics HESI 2023

1. What is an important nursing responsibility when a dysrhythmia is suspected?

Correct answer: C

Rationale: When a dysrhythmia is suspected, an important nursing responsibility is to count the apical pulse for 1 full minute and then compare this rate with the radial pulse rate. This method helps in identifying dysrhythmias as it allows for a direct comparison of the heart's rhythm at two different pulse points. Ordering an immediate electrocardiogram (Choice A) may be necessary but should not be the first step. Counting the radial pulse multiple times (Choice B) is not as accurate as comparing rates directly. Having someone else take the radial pulse simultaneously (Choice D) may introduce errors and inconsistencies in the measurement.

2. A home care nurse is visiting a family for the first time. The 4-week-old infant had surgery for exstrophy of the bladder and creation of an ileal conduit soon after birth. When the nurse arrives, the mother appears tired, and the baby is crying. After an introduction, which is the most appropriate statement by the nurse?

Correct answer: A

Rationale: The most appropriate statement by the nurse in this scenario is to inquire about the family's daily routine. This question allows the nurse to gather information about the family dynamics, the care routine for the infant post-surgery, feeding schedules, and potential stressors. It opens the conversation in a non-intrusive manner and helps the nurse assess the family's situation to provide appropriate support. Choices B, C, and D do not address the situation effectively. Asking about the daily routine is crucial for the nurse to understand the family's needs and offer targeted assistance.

3. After instituting ordered measures to reduce the fever in a 3-year-old with fever and vomiting, what nursing action is most important for the nurse in the emergency department to take?

Correct answer: A

Rationale: Preventing shivering is crucial in this situation as it can increase the body temperature and counteract the effects of antipyretic measures aimed at reducing the fever. Shivering generates heat, potentially worsening the fever. Restricting oral fluids (Choice B) is not appropriate as fluid intake is important to prevent dehydration, especially in a child who has been vomiting. Measuring output hourly (Choice C) and taking vital signs hourly (Choice D) are important nursing actions but not as critical as preventing shivering in this scenario. Therefore, the most important nursing action is to prevent shivering to aid in fever reduction and management.

4. When caring for a child diagnosed with asthma, what is an important nursing intervention?

Correct answer: A

Rationale: Administering bronchodilators is a crucial nursing intervention for a child with asthma as it helps to open the airways and improve breathing. Bronchodilators work by relaxing the muscles around the airways, making breathing easier for the child. Encouraging physical activity may exacerbate asthma symptoms in some cases, so it is not recommended as a primary intervention. Monitoring oxygen saturation is important in assessing respiratory status, but administering bronchodilators would take precedence in this situation. Providing nutritional support is a general nursing intervention and not specific to managing asthma symptoms.

5. What is important to include in discharge instructions for a child who has had a tonsillectomy?

Correct answer: B

Rationale: Encouraging fluid intake is essential post-tonsillectomy to keep the throat moist, aid in healing, and prevent dehydration. Gargling with salt water may irritate the surgical site and is typically avoided to prevent discomfort and irritation. Providing hard candy can be harmful as it may cause trauma to the surgical area and should be avoided to prevent injury. Applying heat to the neck is not recommended as it can increase swelling and discomfort in the surgical region. Therefore, the correct instruction is to encourage fluid intake.

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