HESI: Evolve Resources for HESI Comprehensive Review for the NCLEX-RN Examination (Red Book) Practice Questions

HESI: Evolve Resources for HESI Comprehensive Review

for the NCLEX-RN Examination (Red Book) Practice Questions Leave the first rating Students also studied Terms in this set (13) Science MedicinePaediatrics Save HESI Comprehensive Exit Exam 1 (A...125 terms K_Copeland5Preview

NCLEX EXAM PREVIEW

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HESI 79

798 term nur At which point during the physical examination should a child with asthma be assessed for the presence or absence of intercostal retractions?

• Inspiration
• Coughing
• Apneic Episodes
• Expiration

A.Rationale: Intercostal retractions result from respiratory effort to draw air into restricted airways. The retractions will not be noticeable when air is expelled from the lungs, such as when the client is coughing or expiring. During apnea, the client is not attempting to draw air into the airways. Apnea indicates that the respiratory effort is absent A mother calls the clinic because her 6-year-old son, who has been taking prescribed antibiotics for 7 of the previous 10 days, continues to have a cough that she reports is worsening. Further questioning by the nurse reveals that the cough is nonproductive. What advice should the nurse provide to this mother?

• Watch the boy a few more days and see if the cough

begins to produce sputum.

• The full 10-day course of antibiotics must be

completed before effectiveness can be evaluated.

• Give the child plenty of fluids and an over-the-counter

cough suppressant.

• Bring the child to the clinic today for an examination

related to the cough.D

Rationale: The child should be evaluated as soon as possible for pneumonia.

Antibiotics usually improve symptoms during the first few days of treatment but should be continued for the full prescribed course. A continued cough after 7 days of antibiotic treatment may indicate an infectious process in the lower lungs, which could cause a nonproductive cough. Children with pneumonia can deteriorate unexpectedly and rapidly and can become seriously ill, with no sputum production. Option B delays evaluation too long. Although giving fluids is advisable, cough suppressants might mask symptoms of a serious condition.

The nurse is caring for a child with intussusception who is scheduled for a barium enema prior to a surgical procedure. Which action should the nurse take first?

• Evacuate the bowel of impacted feces
• Administer magnesium sulfate
• Place the child on a clear liquid diet
• Assess the stool for white color

C Rationale: Intussusception, an invagination or telescoping of one portion of the intestine into another, causes intestinal obstruction in children (usually occurs between 3 months and 5 years of age). Nonsurgical treatment is attempted with hydrostatic pressure created by barium instillation, which often reduces the area of bowel intussusception. In preparation for a barium enema, the client should first be placed on a clear liquid diet for the entire day; then magnesium sulfate is administered for bowel evacuation. A barium enema is likely to cause option A.After the enema, white stool may be seen as the body naturally removes any remaining barium.The nurse is teaching an adolescent girl with scoliosis about a Milwaukee brace that her health care provider has prescribed. Which instruction should the nurse provide to this client?

• Remove the brace 1 hour each day for bathing only.
• Remove the brace only for back range-of-motion

exercises.

• Wear the brace against the bare skin to ensure a good

fit.

• Wearing the brace will cure the spinal curvature.

A

Rationale: The Milwaukee brace is designed to slow the progression in spinal

curvature while the adolescent is growing. The brace should be worn 23 hours a day and removed a total of 1 hour a day for hygiene. There are no specific exercises for increasing the range of motion in the back that should be performed. A T shirt should be worn next to the body and the brace put on over the T shirt to protect the skin. The brace will not cure the spinal curvature but should slow the progression of the scoliosis.The nurse expects a 2-year-old child to exhibit which behavior?

• Build a house with blocks.
• Ride a small tricycle 6 feet.
• Display possessiveness with toys.
• Look at a picture book for 15 minutes.

C

Rationale: Two-year-old children are egocentric and unable to share with other

children. Options A, B, and D are behaviors of a preschooler.Which assessment findings should the nurse expect when caring for a child with cystic fibrosis? (Select all that apply.)

• Steatorrhea
• Obesity
• Foul-smelling stools
• Delayed growth
• Pulmonary congestion

A, C, D, and E Rationale: Options A, C, D, and E are all common assessment findings in the client with cystic fibrosis. Weight loss, not weight gain, is associated with cystic fibrosis.An infant is receiving digoxin for congestive heart failure.The apical heart rate is assessed at 80 beats/min. What intervention should the nurse implement?

• Call for a portable chest radiograph.
• Obtain a therapeutic drug level.
• Reassess the heart rate in 30 minutes.
• Administer digoxin immune Fab stat

B Rationale: Sinus bradycardia (heart rate <90>

A 4-year-old child has cystic fibrosis. Which stage of Erikson theory of psychosocial development is the nurse addressing when teaching inhalation therapy?

• Autonomy
• Industry
• Trust
• Initiative

D Children 4 to 5 years of age are in the "Initiative vs. Guilt" stage of Erikson theory of psychosocial development. They enjoy being active and participating in role playing. "Autonomy vs. Shame and Doubt" occurs at 1 to 3 years of age. "Industry vs. Inferiority" occurs at 6 to 11 years; "Trust vs. Mistrust" occurs from birth to 1 year of age.A 3-month-old infant weighing 10lb 15 oz has an axillary temperature of 98.9° F. What caloric amount does this child need?

• 400 calories/day
• 500 calories/day
• 600 calories/day
• 700 calories/day

C Rationale: An infant requires 108 calories/kg/day. The first step is to change 10 lb 15 oz to 10.9 lb. Then convert pounds to kilograms by dividing pounds by 2.2, which is 10.9/2.2 = 4.954 kg, rounded to 5 kg. The second step is to multiply 108 calories/kg/day (108 × 5 = 540 calories/day). However, this infant requires 10% more calories because of the 1° F temperature elevation. Ten percent of 540 (calories/day) is 54, and 540 + 54 = 594. This infant will require approximately 600 calories/day. Options A, B, and D are incorrect.The nurse observes a 4-year-old boy in a day care setting. Which behavior should the nurse expect this child to exhibit?

• Throws a temper tantrum when told he must share the

toys.

• Plays by himself for most of the day.
• Boasts aggressively when telling a story
• Cries and is fearful when separated from his parents.

C Rationale: Four-year-old children are aggressive in their behavior and enjoy telling tales. Options A and D are typical toddler behaviors. A preschooler's play is usually cooperative, so playing alone is not typical.A burned child is brought to the emergency department, and the nurse uses a modified rule of nines to estimate the percentage of the body burned. When calculating the percentage of burn, which parts of the child's body are proportionally larger than an adult's?

• Head and neck
• Arms and chest
• Legs and abdomen
• Back and abdomen

A

Rationale: The standard rule of nines is inaccurate for determining burned body

surface areas with children because a child's head and neck are proportionately larger than an adult's. Specially designed charts are commonly used to measure the percentage of burn in children. Options B, C, and D are not proportionately different.The nurse is preparing a teaching plan for the mother of a child who has been diagnosed with celiac disease.Choosing which lunch will be within the therapeutic management of a child with celiac disease?

• Turkey salad, milk, and oatmeal cookies
• Baked chicken, coleslaw, soda, and frozen fruit dessert
• Tuna salad sandwich on whole wheat bread, milk, and

ice cream

• Turkey sandwich on rye bread, orange juice, and fresh

fruit B

Rationale: A child with celiac disease is managed on a gluten-free diet, which

eliminates food products containing oats, wheat, rye, or barley.

A woman whose first child died at 6 weeks of age because of sudden infant death syndrome (SIDS) is being discharged following the birth of her second child. The mother tells the nurse that she is fearful that this infant will also develop SIDS. Which response is best for the nurse to provide this woman?

• "You can prevent SIDS if your baby sleeps on the side

or back. You will have to monitor the baby carefully."

• "The fear of losing another child to SIDS is very

realistic. Have you thought about what support you may need?"

• "An apnea monitor will alert you if the baby stops

breathing. This will give you the peace of mind that you need."

• "My neighbor's baby died of SIDS last year, and she

went to a SIDS support group. That really helped her." B

Rationale: The most effective way to provide emotional support is to

acknowledge what clients may be feeling, be a sounding board for them so they can listen to themselves, and allow them to discover their own solutions. Option A implies to the mother that she can prevent SIDS from occurring, which is an unrealistic expectation. Offering a personal opinion about what will help this client or about what has helped a neighbor is not as effective as helping the client discover what would be best for her.