HESI LPN
HESI Pediatrics Quizlet
1. Which of the following parameters would be LEAST reliable when assessing the perfusion status of a 2-year-old child with possible shock?
- A. distal capillary refill
- B. systolic blood pressure
- C. skin color and temperature
- D. presence of peripheral pulses
Correct answer: B
Rationale: Systolic blood pressure is the least reliable parameter when assessing the perfusion status of a 2-year-old child with possible shock. In pediatric patients, especially young children, blood pressure may not decrease until significant shock has already occurred, making it a late indicator of inadequate perfusion. Depending solely on systolic blood pressure to evaluate perfusion status in this age group can lead to a delay in appropriate interventions. Distal capillary refill time, skin color, and temperature changes, and the presence of peripheral pulses are more sensitive and early indicators of perfusion status in pediatric patients. Monitoring distal capillary refill provides information on peripheral perfusion, while changes in skin color and temperature can signal circulatory compromise. Evaluating the presence or absence of peripheral pulses offers insights into vascular perfusion. These parameters offer more reliable and prompt feedback on a child's perfusion status compared to systolic blood pressure.
2. A child with a diagnosis of leukemia is admitted to the hospital with a fever. What is the priority nursing intervention?
- A. Administering antibiotics
- B. Administering antipyretics
- C. Providing nutritional support
- D. Monitoring for signs of infection
Correct answer: D
Rationale: The correct answer is D: Monitoring for signs of infection. When a child with leukemia presents with a fever, the priority nursing intervention is to monitor for signs of infection due to the immunocompromised state of the child. Administering antibiotics (choice A) may be necessary based on the assessment of signs of infection, but monitoring comes first. Administering antipyretics (choice B) helps to reduce fever but does not address the underlying cause. Providing nutritional support (choice C) is essential but not the priority when the child is at risk of infection.
3. Why is a client with gestational diabetes being scheduled for an amniocentesis when the fetus has an estimated weight of eight pounds (3629 grams) at 36 weeks gestation? What information is the amniocentesis seeking to obtain?
- A. Presence of a neural tube defect.
- B. Chromosomal abnormalities.
- C. Gender of the fetus.
- D. Fetal lung maturity.
Correct answer: D
Rationale: An amniocentesis in this scenario is most likely being performed to assess fetal lung maturity. This is necessary when considering early delivery due to macrosomia (large fetal size), which is a common concern in gestational diabetes. Evaluating fetal lung maturity is crucial to determine if the fetus's lungs are developed enough to support breathing independently outside the womb. The presence of a neural tube defect and chromosomal abnormalities are not typically assessed through amniocentesis in this situation, and determining the gender of the fetus is not the primary purpose of the procedure here.
4. At the surgical scrub sink, a surgical nurse demonstrated the proper surgical handwashing technique by scrubbing:
- A. With her hands held lower than her elbows
- B. With her hands held higher than her elbows
- C. With her hands in a fist position
- D. With hands placed on her chest
Correct answer: B
Rationale: The correct technique for surgical handwashing involves scrubbing with hands held higher than the elbows. This positioning helps prevent water from the contaminated area (the hands) from flowing towards the cleaner area (the elbows). This directional flow minimizes the risk of contaminating the scrubbed hands during the handwashing process. Choices A, C, and D are incorrect: A - having hands lower than elbows would risk contamination of the clean area, C - using a fist position does not ensure proper coverage and thorough handwashing, and D - placing hands on the chest is not part of the proper surgical handwashing technique.
5. Community Health Nursing (CHN) in the Philippines encompasses healthcare provisions affecting four clients: individuals, families, population groups, and communities. In the course of our community health work, traditional, non-traditional, alternative, or complementary health care strategies are utilized. The legal basis for this action may be derived from the:
- A. PhilHealth Act
- B. Traditional and Alternative Health Care Law
- C. Philippine Nursing Act
- D. Philippine Medical Act
Correct answer: B
Rationale: The correct answer is B: Traditional and Alternative Health Care Law. This law provides the legal basis for integrating alternative health care strategies. The PhilHealth Act (Choice A) focuses on health insurance, the Philippine Nursing Act (Choice C) regulates the nursing profession, and the Philippine Medical Act (Choice D) pertains to the medical profession. These laws are not directly related to the integration of traditional, non-traditional, alternative, or complementary health care strategies in community health work.