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. While performing a visual inspection of a 30-year-old woman in active labor, you can see the umbilical cord at the vaginal opening. After providing high concentration oxygen, you should next

Correct answer: B

Rationale: In the scenario described, when the umbilical cord is visible at the vaginal opening, the priority is to relieve pressure from the cord with gloved fingers. This action helps prevent cord compression and ensures continued oxygenation to the fetus, which is crucial for the baby's well-being. Massaging the uterus or elevating the mother's lower extremities is not the correct course of action in this situation and may potentially worsen the condition. Placing the mother on her left side and providing rapid transport is not the immediate step needed to address the visible umbilical cord; relieving pressure from the cord takes precedence to maintain fetal oxygen supply.

3. What is an important nursing consideration for a child with a diagnosis of juvenile idiopathic arthritis (JIA) being treated with methotrexate?

Correct answer: A

Rationale: The correct answer is to monitor liver function tests regularly. Methotrexate, commonly used in JIA, can be hepatotoxic. Regular monitoring of liver function tests is crucial to detect any signs of liver damage early. While encouraging regular exercise (choice B) is generally beneficial for overall health, it is not directly related to methotrexate therapy. Providing high-calorie snacks (choice C) is not a necessary consideration in this context and can be misleading. Encouraging frequent handwashing (choice D) is important for infection control but is not specifically related to the medication methotrexate.

4. The parents of a 2-year-old child tell the nurse that they are having difficulty disciplining their child. What is the nurse’s most appropriate response?

Correct answer: C

Rationale: The most appropriate response for the nurse is to emphasize the importance of consistency in discipline when dealing with toddlers. Toddlers are at an age where they are learning boundaries and acceptable behaviors. By being consistent, parents can help their child understand what is expected of them and establish a sense of structure and routine. Choices A, B, and D do not provide constructive advice or guidance on how to address the issue of disciplining a 2-year-old. Choice A merely acknowledges the age without providing guidance, choice B seeks more information without offering support, and choice D labels the age without offering practical advice on discipline.

5. The mother of a 5-year-old child with eczema is getting a check-up for her child before school starts. What will the nurse do during the visit?

Correct answer: B

Rationale: During a check-up for a child with eczema, assessing compliance with treatment regimens is a key nursing intervention. This helps ensure that the child is following the prescribed treatment plan effectively, which is crucial in managing eczema and preventing flare-ups. Changing a bandage on a cut is not directly related to managing eczema. Discussing systemic corticosteroid therapy may be part of the visit, but assessing compliance is more immediate and essential. Assessing the child’s fluid volume is important for overall health assessment but not specifically related to managing eczema.

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