Hesi 2020 NP

RN is caring for a 3-y/o child who is 2 hours postop from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?
• BP trend is downward & pulse is rapid & irregular.
• Right foot is cool to touch & appears pale & blanched.
• Pulse distal to femoral artery is weaker on left foot than right.
• Pressure dressing at right femoral area is moist & oozing blood.
2. Following a motor vehicle collision, a 3-y/o girl has a spica cast applied. Which toy is best for RN for this 3 y/o child?
• Duck that squeaks.
• Fashion doll & clothes.
• Set of cloth & hand puppets.
• Hand held video game.
3. An infant with tetralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action should RN implement first?
• Administer morphine sulphate.
• Start IV fluids.
• Place the infant in a knee-chest position.
• Provide 100% oxygen by face mask.
4. Child admitted with diabetic ketoacidosis is demonstrating Kussmaul respirations. RN determines that the increased respiratory rate is a compensatory mechanism for which acid base alteration?
• Metabolic alkalosis.
• Respiratory acidosis.
• Respiratory alkalosis.
• Metabolic acidosis.
5. 7 years old is admitted to hospital with persistent vomiting & a nasogastric tube attached to low intermittent suction is applied. Which finding is most important for RN to report to Dr?
• Gastric output of 100 mL in the last 8 hours.
• Shift intake of 640 mL IV fluids plus 30 mL PO ice chips.
• Serum potassium of 3.0 mg/dL.
• Serum pH of 7.45.
6. RN is evaluating diet teaching for Pt who has nontropical sprue (celiac disease). Choosing which food indicates effective teaching?
• Creamed corn.
• Pancakes.
• Rye crackers.
• Cooked oatmeal.
7. During a well-baby check, RN hides a block under baby’s blanket & baby looks for block. Which normal growth & development milestone is baby developing?
• Separation anxiety.
• Associative play.
• Object prehension.
• Object permanence.
8. The RN is measuring the frontal occipital circumference (FOC) of a 3-months old infant, & notes that the FOC has increased 5 inches since birth & the child’s head appears large in relation to body size. Which action is most important for RN to take next?
• Measure the infant’s head-to-toe length.
• Palpate the anterior fontanel for tension & bulging.
• Observe the infant for sunken eyes.
• Plot the measurement on the infant’s growth chart.
9. The RN is preparing 10 year old with accelerated forehead for suturing. Both parents & 12 y/o sibling are at the child’s bedside. Which instruction best supports family?
• While waiting for Dr, only one visitor may stay with the child.
• All of you should leave while Dr sutures the child’s forehead.
• It is best if sibling goes to waiting room until suturing is completed.
• Please decide who will stay when Dr begins suturing.