the practical nurse pn is preparing to administer a tube feeding to a child before starting the feeding what should the pn assess
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Nursing Elites

HESI RN

HESI Practice Test Pediatrics

1. Before administering a tube feeding to a child, what should the practical nurse (PN) assess?

Correct answer: A

Rationale: Assessing tube placement is critical before initiating a tube feeding to verify its correct positioning in the stomach. This assessment helps prevent potential complications such as aspiration if the tube is incorrectly placed in the respiratory tract. Checking bowel sounds, abdominal circumference, and tube patency are important assessments in the care of a child receiving tube feedings, but ensuring proper tube placement takes precedence to ensure safe and effective delivery of nutrition.

2. A child with leukemia is admitted for chemotherapy, and the nursing diagnosis 'altered nutrition, less than body requirements related to anorexia, nausea, and vomiting' is identified. Which intervention should the nurse include in this child's plan of care?

Correct answer: B

Rationale: Allowing the child to eat any food desired and tolerated is the most appropriate intervention in this scenario. Anorexia, nausea, and vomiting are common side effects of chemotherapy, which can lead to altered nutrition. Allowing the child to choose foods they desire and can tolerate can help improve their nutritional intake during this challenging time. Encouraging large portions of food at every meal (Choice A) may overwhelm the child and worsen their symptoms. Eating like siblings at home (Choice C) may not align with the child's specific needs during chemotherapy. Restricting food from fast-food restaurants (Choice D) is not necessary as long as the food choices are suitable for the child's condition and preferences.

3. In a 12-year-old child with a history of epilepsy brought to the emergency department after experiencing a 10-minute seizure, what is the nurse’s priority intervention?

Correct answer: B

Rationale: Administering antiepileptic medication as prescribed is the priority intervention in a child with a history of epilepsy who experienced a prolonged seizure. This action is crucial to stop the seizure and prevent further complications associated with prolonged seizure activity. Administering oxygen may be necessary, but the priority is to stop the seizure. Monitoring vital signs and checking blood glucose levels are important but secondary to administering antiepileptic medication to manage the seizure.

4. After reinforcing information on treating a sprained ankle, what statement by the adolescent indicates to the practical nurse that further instruction is needed?

Correct answer: C

Rationale: The correct answer is C. Applying warm compresses to a sprained ankle within the first 24 hours is incorrect as it can increase swelling and inflammation. Instead, cold compresses are recommended to help reduce swelling and pain. Option A, keeping the leg elevated, helps in reducing swelling. Option B, wrapping the ankle in an elastic bandage, provides support. Option D, using an ice pack in intervals, is effective in reducing swelling and pain. Therefore, the statement about applying warm compresses indicates the need for further instruction.

5. A child who is admitted to the hospital with anemia is anxious, fearful, and hyperventilating. The nurse anticipates the child developing which acid-base imbalance?

Correct answer: C

Rationale: In this scenario, the child is hyperventilating, which leads to excessive loss of carbon dioxide. This loss of carbon dioxide causes respiratory alkalosis due to a decrease in the partial pressure of carbon dioxide in the blood. Therefore, the correct answer is respiratory alkalosis. Choices A, B, and D are incorrect. Metabolic acidosis is characterized by a decrease in pH and bicarbonate levels due to conditions like kidney disease. Respiratory acidosis is caused by retention of carbon dioxide, leading to an increase in the partial pressure of carbon dioxide. Metabolic alkalosis results from a loss of acid or an increase in bicarbonate levels.

Similar Questions

During a well-baby check of a 7-month-old infant, the practical nurse notes an absence of babbling. Which focused assessment should the PN implement?
The nurse is caring for a 14-year-old adolescent who was admitted to the hospital after a suicide attempt. The adolescent’s mood appears stable, and the healthcare provider has recommended discharge. What is the nurse’s priority action?
A 9-year-old child is brought to the clinic with complaints of fatigue, pallor, and shortness of breath. The nurse notes that the child has a history of iron-deficiency anemia. What is the nurse’s priority action?
A 5-year-old child with leukemia is receiving chemotherapy. The nurse notes that the child’s white blood cell count is low. What is the nurse’s priority intervention?
The practical nurse is caring for a child with suspected appendicitis. Which assessment finding should be reported to the healthcare provider immediately?

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