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Evolve HESI peds Practice QuestionsA 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. - answersApical 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. -
answersAdminister 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. - answersUse 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. - answersObserve 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 - answersPrevent 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. - answersA. 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." - answersPut 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. -
answersAdminister 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.
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