HESI LPN
Pediatrics HESI 2023
1. What is an important nursing responsibility when a dysrhythmia is suspected?
- A. order an immediate electrocardiogram
- B. count the radial pulse every 1 minute for five times
- C. count the apical pulse for 1 full minute, and compare the rate with the radial pulse rate
- D. have someone else take the radial pulse simultaneously with the apical pulse
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. The nurse is teaching a community group about risks of cardiovascular disease. Several clients ask the nurse to determine their risk. Which client should the nurse identify as having the greatest risk for cardiovascular disease?
- A. A male with a serum cholesterol level of 199 mg/dl.
- B. A female with a serum cholesterol level of 201 mg/dl.
- C. A male with a low-density lipoprotein (LDL) level of 200 mg/dl.
- D. A female with a low-density lipoprotein (LDL) level of 160 mg/dl.
Correct answer: C
Rationale: The correct answer is C. A male with a high LDL level (200 mg/dl) has a significant risk for cardiovascular disease. High levels of LDL cholesterol are associated with an increased risk of atherosclerosis and heart disease. Choices A, B, and D have serum cholesterol levels that are slightly elevated but are not as specific or directly linked to cardiovascular risk as high LDL levels. Therefore, the client with the high LDL level is at the greatest risk for cardiovascular disease.
3. The PN observes a UAP preparing to exit a client's room. The UAP's hands appear visibly soiled as the UAP uses a hand rub for 19 seconds to cleanse the hands. Which action should the PN take?
- A. Confirm that the UAP completed hand hygiene correctly
- B. Instruct the UAP to wash the hands for one minute
- C. Ask the UAP why the hands were so obviously soiled
- D. Advise the UAP to use the hand rub for 30 seconds
Correct answer: D
Rationale: When hands are visibly soiled, they should be washed with soap and water for at least 20 seconds. However, when using hand rub, it should be applied for at least 30 seconds to be effective. In this scenario, the UAP's hands were visibly soiled, indicating the need for thorough cleaning. Advising the UAP to use the hand rub for 30 seconds is essential to ensure proper hand hygiene and reduce the risk of spreading infection. Choices A, B, and C are incorrect because confirming completion of hand hygiene, instructing to wash for one minute, or asking why the hands were soiled do not address the immediate need for proper hand hygiene in the given situation.
4. When working with a client who does not speak the same language as the nurse and an interpreter is present, which of the following actions should the nurse take?
- A. Talk directly to the client, instead of the interpreter, when speaking.
- B. Speak loudly to the interpreter.
- C. Use gestures to communicate with the client.
- D. Avoid using an interpreter and rely on family members.
Correct answer: A
Rationale: When caring for a client who speaks a different language, it is essential to communicate through an interpreter. Talking directly to the client, rather than the interpreter, ensures clear and respectful interaction. Speaking loudly to the interpreter (choice B) is not necessary and may be perceived as disrespectful. Using gestures (choice C) alone may lead to misunderstandings or misinterpretations. Avoiding the use of an interpreter and relying solely on family members (choice D) can compromise the accuracy and confidentiality of the communication.
5. After a hip replacement surgery, a client is instructed to use an abduction pillow while in bed. What is the primary purpose of this device?
- A. To reduce the risk of blood clots.
- B. To prevent hip dislocation.
- C. To improve circulation in the legs.
- D. To alleviate pain and discomfort.
Correct answer: B
Rationale: The primary purpose of using an abduction pillow after hip replacement surgery is to prevent hip dislocation. The abduction pillow keeps the legs separated, which reduces the risk of hip dislocation by preventing excessive internal rotation and adduction of the hip joint. Choices A, C, and D are incorrect as the main goal of using the abduction pillow is to maintain proper positioning and stability of the hip joint to prevent dislocation, rather than addressing blood clots, circulation, or pain relief.