Pediatric HESI Test Bank

HESI LPN

1. A child sitting on a chair in a playroom starts to have a tonic-clonic seizure with a clenched jaw. What is the nurse’s best initial action?

A. Attempt to open the jaw.
B. Place the child on the floor.
C. Call out for assistance from staff.
D. Place a pillow under the child’s head.

Correct answer: B

Rationale: The correct initial action during a tonic-clonic seizure is to place the child on the floor to prevent injury. This action helps protect the child from falling off the chair and provides a safer environment for the seizure to occur. Attempting to open the jaw can cause harm or injury. Calling out for assistance is important but should follow the immediate action of moving the child to the floor. Placing a pillow under the child’s head is not recommended as it may lead to airway obstruction or further injury during the seizure.

2. What is an early sign of congestive heart failure that the nurse should recognize?

A. Tachypnea
B. Bradycardia
C. Inability to sweat
D. Increased urinary output

Correct answer: A

Rationale: Tachypnea, which refers to rapid breathing, is an early sign of congestive heart failure. In heart failure, the heart's inability to pump efficiently can lead to fluid accumulation in the lungs, causing the child to breathe faster to try to compensate for the decreased oxygen exchange. Bradycardia (slow heart rate) is not typically associated with congestive heart failure; instead, it may indicate a different issue. Inability to sweat is not a common early sign of congestive heart failure. Increased urinary output is not a typical early sign of congestive heart failure; instead, it may be a sign of other conditions like diabetes or kidney issues.

3. When caring for a child diagnosed with bronchiolitis, what is the priority nursing intervention?

A. Administering bronchodilators
B. Providing respiratory therapy
C. Monitoring oxygen saturation
D. Encouraging fluid intake

Correct answer: B

Rationale: The priority nursing intervention for a child with bronchiolitis is providing respiratory therapy. This intervention aims to maintain airway patency, optimize oxygenation, and support effective breathing. Administering bronchodilators, though important, may not be the initial priority as respiratory therapy takes precedence in ensuring adequate oxygenation and ventilation. Monitoring oxygen saturation is crucial but is usually part of the ongoing assessment following the initiation of respiratory therapy. Encouraging fluid intake is essential for hydration but is not the priority intervention when addressing the respiratory distress associated with bronchiolitis.

4. A nurse in the emergency department observes large welts and scars on the back of a child who has been admitted for an asthma attack. What additional information must be included in the nurse’s assessment?

A. History of an injury
B. Signs of child abuse
C. Presence of food allergies
D. Recent recovery from chickenpox

Correct answer: B

Rationale: The correct answer is B: Signs of child abuse. Large welts and scars on a child may be indicative of abuse, making it crucial for the nurse to assess and report any suspicions. Assessing the history of an injury (choice A) may not provide insight into the cause of the welts and scars as effectively as looking for signs of potential abuse. Food allergies (choice C) and recent recovery from chickenpox (choice D) are not directly relevant to the observation of welts and scars on the child's back.

5. Which cardiac defects are associated with tetralogy of Fallot?

A. Right ventricular hypertrophy, atrial and ventricular defects, and mitral valve stenosis
B. Origin of the aorta from the right ventricle and of the pulmonary artery from the left ventricle
C. Right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding aorta
D. Altered connection between the pulmonary artery and the aorta, right ventricular hypertrophy, and an atrial septal defect

Correct answer: C

Rationale: Tetralogy of Fallot is characterized by a combination of four specific cardiac defects: right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding aorta. Choice A is incorrect as it includes mitral valve stenosis, which is not typically part of tetralogy of Fallot. Choice B describes transposition of the great arteries rather than tetralogy of Fallot. Choice D includes an atrial septal defect, which is not part of the classic presentation of tetralogy of Fallot.