Pediatric HESI Test Bank

Pediatric HESI Test Bank Related

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After cancer chemotherapy, a client experiences nausea and vomiting. The nurse should highest priority to which intervention?

  • A. Serving small portions bland food
  • B. Encouraging rhythmic breathing exercises
  • C. Administering metoclopramide (Reglan) and dexamethasone (Decadron) as prescribed
  • D. Withholding fluids for the first 4 to 6 hours after chemotherapy administration
Correct Answer: C

Rationale: Administering metoclopramide (Reglan) and dexamethasone (Decadron) as prescribed should be the highest priority intervention for a client experiencing nausea and vomiting after cancer chemotherapy. Metoclopramide is a commonly used antiemetic medication that helps to reduce nausea and vomiting by enhancing gastric emptying and decreasing nausea. Dexamethasone, a corticosteroid, can also help alleviate inflammation that may contribute to the nausea and vomiting. By administering these medications as prescribed, the nurse can effectively address the client's symptoms and improve their comfort level. The other options, such as serving small portions bland food, encouraging rhythmic breathing exercises, and withholding fluids, are important interventions but should not take precedence over providing the prescribed antiemetic medications to manage the client's post-chemotherapy symptoms.

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The nurse administered neutral protamine Hagedorn (NPH) insulin to a diabetic client at 7am. At what time would the nurse expect the client to be at most risk for a hypoglycemic reaction?

  • A. 10:00 AM
  • B. 4:00 PM
  • C. Noon
  • D. 10:00 PM
Correct Answer: D

Rationale: NPH insulin typically peaks in its action around 6-10 hours after administration. Therefore, after administering NPH insulin at 7am, the client would be at most risk for a hypoglycemic reaction around 10pm. This is when the insulin is exerting its strongest effect, potentially leading to lower blood sugar levels. Monitoring for hypoglycemia during this time frame is crucial to ensure prompt intervention if needed.

When the patient's signature is witnessed by the nurse on the surgical consent, which of the following does the nurse's signature indicate?

  • A. The nurse obtained informed consent.
  • B. The nurse provided informed consent.
  • C. The nurse answered all surgical procedure questions.
  • D. The nurse verified that the patient signed the consent.
Correct Answer: D

Rationale: The nurse's signature on the surgical consent form indicates that the nurse has verified and confirmed that the patient has signed the consent form. This step is crucial to ensure that the patient has voluntarily given their consent for the surgical procedure. It does not mean that the nurse obtained or provided informed consent, answered all surgical procedure questions, or made decisions on behalf of the patient. The nurse's role is to act as a witness to the patient's signature on the consent form to acknowledge that the patient has agreed to the procedure and signed the document.

Which of the following respiratory conditions is always considered a medical emergency?

  • A. Asthma
  • B. Cystic fibrosis (CF)
  • C. Epiglottiditis
  • D. Laryngotracheobronchitis (LTB)
Correct Answer: C

Rationale: Epiglottiditis is always considered a medical emergency due to the potential risk of airway obstruction. The epiglottis is a flap of tissue that prevents food and liquids from entering the airway during swallowing. If the epiglottis becomes inflamed or infected, it can swell and block the airway, making it difficult or impossible for the person to breathe. This obstruction can rapidly progress to a life-threatening situation if not treated promptly. Therefore, epiglottiditis requires immediate medical attention to ensure the airway remains open and the individual can breathe properly.

Other signs of hypovolemia includes all of the following except:

  • A. Dry mucous membranes and soft eyeballs
  • B. Increased hematocrit and hemoglobin
  • C. Decreased pulse rate and widened pulse pressure
  • D. Increased lethargy and confusion
Correct Answer: A

Rationale: When assessing for signs of hypovolemia, dry mucous membranes and soft eyeballs are actually indicative of dehydration, not specifically hypovolemia. In hypovolemia, the body loses both fluid and electrolytes, leading to decreased circulating blood volume. Other signs of hypovolemia include increased hematocrit and hemoglobin levels due to hemoconcentration, decreased pulse rate and widened pulse pressure as compensatory mechanisms to maintain perfusion to vital organs, and increased lethargy and confusion due to impaired perfusion to the brain.

When taking the blood pressure of a client who has AIDS the nurse must;

  • A. Wear a mask and gown
  • B. Use barrier techniques
  • C. Wash the hands thoroughly
Correct Answer: B

Rationale: When taking the blood pressure of a client with AIDS, it is important for the nurse to use barrier techniques to prevent the potential transmission of infection. This includes wearing gloves to protect against exposure to blood or other bodily fluids, using disposable blood pressure cuffs and stethoscopes, and ensuring proper hand hygiene before and after the procedure. Barrier techniques help minimize the risk of cross-contamination and protect both the healthcare provider and the client from potential infections.

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