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. - CORRECT ANS A...
PEDIATRICS HESI TESTBANK 2023
LATEST EXAM GRADED A+
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. - CORRECT 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.
,PEDIATRICS HESI TESTBANK 2023
LATEST EXAM GRADED A+
Ensure respiratory therapy is done daily during any respiratory infection. -
CORRECT 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. - CORRECT 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
,PEDIATRICS HESI TESTBANK 2023
LATEST EXAM GRADED A+
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. - CORRECT 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.
, PEDIATRICS HESI TESTBANK 2023
LATEST EXAM GRADED A+
Reduce peripheral tissue hypoxia and nailbed clubbing - CORRECT 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. - CORRECT 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.
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