Evolve HESI peds Practice Questions
A 6-month-old infant with congestive heart failure (CHF) is receiving digoxin elixir. Which observation by
the nurse warrants immediate intervention?
Apical heart rate of 60.
Sweating across the forehead.
Doesn't suck well.
Respiratory rate of 30 breaths p...
Evolve HESI peds Practice Questions
A 6-month-old infant with congestive heart failure (CHF) is receiving digoxin elixir. Which observation by
the nurse warrants immediate intervention?
Apical heart rate of 60.
Sweating across the forehead.
Doesn't suck well.
Respiratory rate of 30 breaths per minute. Ans- Apical heart rate of 60.
A heart rate of 60 (A) is much lower than normal for a 6-month-old and warrants immediate
intervention. The normal heart rate for a 6-month-old is 80 to 150 BPM when awake, and a rate of 70
while sleeping is considered within normal limits. (B and C) are expected symptoms of heart failure in an
infant. (D) is within normal limits for an infant.
The nurse is teaching the parents of a 5-year-old with cystic fibrosis about respiratory treatments. Which
statement indicates to the nurse that the parents understand?
Perform postural drainage before starting aerosol therapy.
Give respiratory treatments when the child is coughing a lot.
Administer aerosol therapy followed by postural drainage before meals.
Ensure respiratory therapy is done daily during any respiratory infection. Ans- Administer aerosol
therapy followed by postural drainage before meals.
Postural drainage for a child with cystic fibrosis is most effective when performed after nebulization and
before meals (C) or at least 1 hour after eating to prevent nausea and vomiting. Postural drainage uses
gravity to promote mucous removal after nebulization (A) treatments which open the airways.
Pulmonary toileting or respiratory treatments should be given 3 to 4 times daily, not episodically (B and
D).
A female teenager is taking oral tetracycline HCL (Achromycin V) for acne vulgaris. What is the most
important instruction for the nurse to include in this client's teaching plan?
Use sunscreen when lying by the pool.
Cleanse the skin at least 4 times a day.
Take the medication with a glass of milk.
,Menstrual periods may become irregular. Ans- Use sunscreen when lying by the pool.
Photosensitivity is a common side effect of tetracycline HCL (Achromycin V) therapy. Severe sunburn can
occur with minimal sun exposure and clients should be instructed to avoid sunlight and to use sunscreen
(A). (B and D) are not related to tetracycline HCL (Achromycin V) therapy. (C) should be avoided because
dairy products interfere with the absorption of tetracyclines.
What preoperative nursing intervention should be included in the plan of care for an infant with pyloric
stenosis?
Monitor for signs of metabolic acidosis.
Estimate the quantity of diarrhea stools.
Place in a supine position after feeding.
Observe for projectile vomiting. Ans- Observe for projectile vomiting.
Projectile vomiting (D), which contributes to metabolic alkalosis (A), is the classic sign of pyloric stenosis.
(B) is not indicated. (C) is dangerous, due to the potential for aspiration with frequent vomiting.
An infant is born with a ventricular septal defect (VSD) and surgery is planned to correct the defect. The
nurse recognizes that surgical correction is designed to achieve which outcome?
Stop the flow of unoxygenated blood into systemic circulation.
Increase the flow of unoxygenated blood to the lungs.
Prevent the return of oxygenated blood to the lungs.
Reduce peripheral tissue hypoxia and nailbed clubbing Ans- Prevent the return of oxygenated blood to
the lungs.
Closure of VSDs stops oxygenated blood from being shunted from the left ventricle to the right ventricle
(C). VSDs are acyanotic defects, which means that no unoxygenated blood enters the systemic
circulation (A and B). (D) is common with Tetrology of Fallot, which is a cyanotic defect.
A 3-week-old newborn is brought to the clinic for follow-up after a home birth. The mother reports that
her child bottle feeds for 5 minutes only and then falls asleep. The nurse auscultates a loud murmur
characteristic of a ventricular septal defect (VSD), and finds the newborn is acyanotic with a respiratory
,rate of 64 breaths per minute. What instruction should the nurse provide the mother to ensure the
infant is receiving adequate intake? (Select all that apply.)
A. Monitor the the infant's weight and number of wet diapers per day.
B. Increase the infant's intake per feeding by 1 to 2 ounces per week.
C. Mix the dose of prophylactic antibiotic in a full bottle of formula.
D. Allow the infant to rest and refeed on demand or every 2 hours.
E. Use a softer nipple or increase the size of the nipple opening. Ans- A. Monitor the the infant's weight
and number of wet diapers per day.
B. Increase the infant's intake per feeding by 1 to 2 ounces per week.
D. Allow the infant to rest and refeed on demand or every 2 hours.
E. Use a softer nipple or increase the size of the nipple opening.
Antibiotic prophylaxis is recommended for infants with VSDs, but should not be mixed in a bottle of
formula (C) because it is difficult to ensure that the total dose is consumed.
They should be monitored for weight gain and at least 6 wet diapers per day (A). A one-month old infant
should ingest 2 to 4 ounces of formula per feeding and progress to about 30 ounces per day by 4-
months of age (B)
Preoperative nursing care for a child with Wilms' tumor should include which intervention?
Gently percuss the abdomen for evidence of trapped air.
Observe the abdomen for any noticeable discolorations.
Apply cold compresses to the abdomen to reduce edema.
Put a sign on the bed reading, "DO NOT PALPATE ABDOMEN." Ans- Put a sign on the bed reading, "DO
NOT PALPATE ABDOMEN."
Prevention of abdominal palpation (D) minimizes the risk of rupturing the encapsulated tumor and
subsequent metastasis. (A) is unnecessary, and this action could traumatize the tumor in the same
manner as palpation. (B and C) are incorrect since the abdomen is not discolored and cold compresses
are not indicated.
, At 8 a.m. the unlicensed assistive personnel (UAP) informs the charge nurse that a female adolescent
client with acute glomerulonephritis has a blood pressure of 210/110. The 4 a.m. blood pressure reading
was 170/88. The client reports to the UAP that she is upset because her boyfriend did not visit last night.
What action should the nurse take first?
Give the client her 9 a.m. prescription for an oral diuretic early.
Administer PRN prescription of nifedipine (Procardia) sublingually.
Notify the healthcare provider and inform the nursing supervisor of the client's condition.
Attempt to calm the client and retake the blood pressure in thirty minutes. Ans- Administer PRN
prescription of nifedipine (Procardia) sublingually.
Sublingual Procardia (B) lowers blood pressure very quickly, and this should be done first. (A) may also
be done, but oral diuretics do not work as rapidly as the sublingual antihypertensive. When notifying the
healthcare provider, the first thing he/she will want to know is if the PRN antihypertensive has been
administered (C). (D) does not consider the seriousness of this finding. The nurse should stay with the
client until the blood pressure is reduced.
The nurse is assessing an 8-month-old child who has a medical diagnosis of Tetrology of Fallot. Which
symptom is this client most likely to exhibit?
Bradycardia.
Machinery murmur.
Weak pedal pulses.
Clubbed fingers. Ans- Clubbed fingers.
Tetrology of Fallot, a cyanotic heart defect, causes clubbing of fingers and toes (D) due to tissue hypoxia.
Tachycardia, not (A), is a manifestation of congenital heart disease. (B) is a classic sign of ventricular
septal defect. (C) is characteristic of coarctation of the aorta.
Surgery is being delayed for an infant with undescended testes. In collaboration with the healthcare
provider and the family, which prescription should the nurse anticipate?
A trial of adrenocorticotrophic hormone injections.
Frequent stimulation of the cremasteric reflex.
A trial of human chorionic gonadotrophic hormone.
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