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. The healthcare provider is assessing the 'resilience' of a 16-year-old boy. Which exemplifies an external protective factor that may help promote resilience in this child?

Correct answer: C

Rationale: A caring relationship with family members is an external protective factor that promotes resilience in individuals, especially in adolescents. This support system provides a sense of security, stability, and emotional connection, which can help the teenager navigate challenges and setbacks. Choices A, B, and D allude to internal factors related to personal decision-making, self-awareness, and goal management, which are important but do not directly represent external protective factors involving external relationships or resources.

3. 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.

4. The nurse is assessing a child with a possible fracture. What would the nurse identify as the most reliable indicator?

Correct answer: B

Rationale: Point tenderness is the most reliable indicator of a possible fracture in a child. It is a localized tenderness experienced when pressure is applied to a specific area, suggesting a potential fracture. This tenderness is considered more specific to a fracture than other symptoms such as lack of spontaneous movement, bruising, or inability to bear weight. Lack of spontaneous movement and inability to bear weight can be present in various musculoskeletal injuries, while bruising may not always be immediate or specific to a fracture.

5. During a clinical conference with a group of nursing students, the instructor is describing burn classification. The instructor determines that the teaching has been successful when the group identifies what as characteristic of full-thickness burns?

Correct answer: D

Rationale: Full-thickness burns are characterized by a leathery, dry appearance with numbness due to nerve damage. Choice A describes characteristics of superficial burns, which are not full-thickness. Choice B describes characteristics of partial-thickness burns with intact blisters, not full-thickness burns. Choice C describes characteristics of partial-thickness burns with blistering and swelling, not full-thickness burns.

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