Week 1 HESI/ EAQs Flashcards
Which assessment findings will lead the nurse to believe an infant is moderately dehydrated?
Rectal temperature of 99°F (37.2°C), heart rate (HR) of 120 beats/minute, and a respiratory rate of 28 breaths/minute.
A sunken fontanel, dry mucous membranes, and HR of 160 beats/minute.
Warm skin, rectal temperature of 100°F (37.8°C), and blood pressure 100/60 mmHg.
Two wet diapers within the past 8 hours, +3 edema of feet, and a respiratory rate of 30 breaths/minute.
A sunken fontanel, dry mucous membranes, and HR of 160 beats/minute.
Classification of dehydration, based on the serum sodium level 130 to 150 mEq/L (130 to 150 mmol/L), is ___________ (sodium and water are lost in equal proportion).
isonatremic
Fluid replacement for dehydration begins with a fluid bolus of ________________ 0.9% using the formula 20 mL/kg over 20 min.
sodium chloride
Which is the most reliable indicator for fluid loss in the pediatric client?
Daily assessment of skin turgor.
Daily weights at the same time each morning.
The number of wet diapers per shift.
Daily intake and output.
Daily weights at the same time each morning.
During the hourly rounds, the nurse notices that the intravenous fluids (IVF) did not infuse at the prescribed rate.
What should be the nurse’s initial intervention?
Double the fluid rate for 20 minutes until the correct amount of fluid is received.
Notify the HCP immediately.
Assess the IV site for signs of infiltration.
Offer the infant oral fluids to account for the fluids he didn’t receive via IV.
Assess the IV site for signs of infiltration.
Which are the best muscles to use for multiple intramuscular injections (IM) for a 7-month-old infant, based on the principles of growth and development?
Ventrogluteal and dorsogluteal.
Vastus lateralis and ventrogluteal.
Deltoid and dorsogluteal.
Deltoid and vastus lateralis.
Vastus lateralis and ventrogluteal.
Following the administration of the client’s vaccinations, the nurse continues to educate the family regarding safety measures. Which safety measures should the nurse teach the family?
Freely sprinkle baby powder on skin after bathing to keep the skin moist.
Offer a bottle of juice at bedtime to keep the child full during the night.
Position on the right side or the left side for napping.
Place in the backseat in a rear-facing car seat when traveling.
Place in the backseat in a rear-facing car seat when traveling.
What does the pediatric nurse understand as the gold standard for verification of the NGT placement?
Aspiration.
X-ray.
pH testing.
Auscultation.
X-ray.
Based on the 2012 safety alert issued by the Child Health Patient Safety Organization, which method for NGT placement verification is no longer recommended?
pH testing.
X-ray.
Aspiration.
Auscultation.
Auscultation.
What are the principles of fluid balance in infants?
Infants have a greater percent of fluid in the extracellular compartment compared to adults therefore, they have greater and more rapid fluid losses.
Due to their small size, infants have a smaller body surface area for loss of insensible fluid compared to adults.
Because infants have a greater body surface area than adults, they have a higher basal metabolic rate than adults.
An infant’s kidney concentrates and dilutes solute efficiently at birth.
Infants have a greater percent of fluid in the extracellular compartment compared to adults therefore, they have greater and more rapid fluid losses.
The nurse suspects the infant may be experiencing water intoxication. Which findings confirm this assessment? (Select all that apply. One, some, or all options may be correct.)
Weak, slow pulse.
Irritability.
Specific gravity of 1.005.
Moist rales bilaterally.
Sodium level of 140 mEq/L (140 mmol/L).
Irritability.
Specific gravity of 1.005.
Moist rales bilaterally.
The infant is admitted to the NICU and the healthcare provider (HCP) prescribes diuretics. Which is a priority nursing intervention?
Monitor vital signs every 4 hours.
Implement seizure precautions.
Insert a urinary catheter for accurate measurement of intake & output.
Postpone neurologic assessments until admission is complete.
Implement seizure precautions.
Fluid and electrolyte imbalances can cause seizures.
Which nutrition option is best suited for the infant, given the family has chosen formula feeding?
Concentrated powder formula mixed with fluoridated bottled water.
Eight feedings a day of commercial formula for the first 6 months.
Undiluted commercial iron-fortified formula for the first 6 months, not to exceed 32 ounces per day.
Commercial formula feedings supplemented with rice cereal before bedtime to facilitate sleep.
Undiluted commercial iron-fortified formula for the first 6 months, not to exceed 32 ounces per day.
Iron-fortified formula provides all the nutrients an infant needs for the first 6 months of life.
The infant’s baseline weight at 8-months of age is 8.4 kg. On presentation to the ED, the infant’s weight is 7.7 kg. Based on weight loss, what degree of dehydration is the infant exhibiting?
Mild.
Moderate.
Severe.
Critical.
Moderate.
The infant has lost 0.7 kgs, which is approximately 8% of body weight. This is consistent with moderate dehydration.
The infant’s temperature is 101.3° F (38.5° C). What impact does this have on an infant’s fluid needs?
Increases fluid needs by 3%.
Increases fluid needs by 6%.
Increases fluid needs by 9%.
Increases fluid needs by 12%.
Increases fluid needs by 12%.
Which statement reflects the principles of fluid and electrolyte imbalance in hypertonic/hypernatremic dehydration?
Hypertonic dehydration can cause a greater proportion of extracellular fluid loss and lead to more severe physical signs.
Fluid movement is from the extracellular to the intracellular compartment with profound consequences for shock.
Fluids must be administered carefully to avoid serious complications.
Signs of shock will be readily apparent.
Fluids must be administered carefully to avoid serious complications.
Rapid fluid replacement may result in water intoxication and marked cerebral edema.
Which nursing assessment is most indicative the infant’s clinical condition is improving?
Urine output of 0.5 mL/kg/hr.
Serum sodium of 140 mEq/L (140 mmol/L).
Urine specific gravity of 1.020.
Capillary refill >2 seconds.
Serum sodium of 140 mEq/L (140 mmol/L).
Expected serum sodium levels for infants are 130 to 150 mEq/L (130 to 150 mmol/L). Normal sodium levels are considered part of quality patient outcomes for dehydration.
Fluid losses with _________ in infants are more serious and severe than in adults. The caregiver should seek treatment for __________ within the first 24 hours of the illness.
diarrhea
The caregiver is encouraged to room-in while the infant is in the pediatric unit, but expresses concern about missing work. The infant exhibits signs of distress in the caregiver’s absence.
The infant screams when his caregiver leaves, resists being held by the nurse, and is inconsolable. How does the nurse accurately interpret his behavior?
An indicator of non-nurturing.
The protest stage of separation anxiety.
Despair due to separation anxiety.
Indicators of a child with a behavior problem.
The protest stage of separation anxiety.
The caregiver expresses concern that visits are upsetting to infant and offers to curtail visiting.
Which intervention should the nurse recommend will best meet the infant’s emotional needs related to separation anxiety?
Advise the caregiver there is no need to return until the infant is ready for discharge.
Empathize that it is difficult to see the infant upset but that their presence is needed.
Convince the caregiver it is vital to the infant’s health and they should reconsider rooming-in.
Explain to the caregiver the unit does not have the resources to allow a staff member to be with the infant around the clock.
Empathize that it is difficult to see the infant upset but that their presence is needed.
Parental presence, even if limited, is beneficial. Discuss alternative strategies for ameliorating the client’s anxiety with the caregiver.
Which nursing intervention is most appropriate to treat diaper dermatitis?
Keep the diaper area open to air for 20 minute intervals every 4 hours.
Apply a generous layer of zinc oxide.
Scrub the area with antimicrobial soap after each bowel movement.
Use commercial baby wipes to clean the skin.
Apply a generous layer of zinc oxide.
Zinc oxide or petroleum can be used to create a skin barrier when the skin is red, moist, and has open areas.
_____ oxide or petroleum can be used to create a skin barrier when the skin is red, moist, and has open areas.
Zinc
The healthcare provider (HCP) also prescribes an IV dose of ondansetron. The caregiver asks about the purpose of this drug. How should the nurse respond?
“This medication helps to improve appetite.”
“This medication is to stop the vomiting.”
“This medication is to replace electrolytes lost from vomiting.”
“This medication will cause drowsiness.”
“This medication is to stop the vomiting.”
“It is normal for toddlers to regress to a prior developmental level during ____________.”
hospitalization
Which method would the nurse use to measure the output of a hospitalized 10-month-old?
Collect the patient’s urine
Measure the patient’s weight
Count the number of wet diapers
Weigh of the patient’s wet diapers
Weigh of the patient’s wet diapers
Which is the most consistent indicator of pain in infants?
Increased heart rate
Increased respirations
Clenching the teeth and lips
Facial expression of discomfort
Facial expression of discomfort
The registered nurse asks a student nurse to measure the temperature of a 2-year-old child. Through which route does the student nurse measure the child’s temperature?
Oral
Rectal
Axillary
Tympanic
Axillary
Which infant behavior did the nurse most likely observe when inferring the newborn baby is well attached to the parents?
Used appealing facial expressions.
Sought attention from other adults.
Body movements were jerky when touched.
Unresponsive to the parents’ caregiving.
Used appealing facial expressions.
Which would the nurse suggest that the patient do to comfort a fussy infant who is irritated after feeding?
“Sing and coo to the infant.”
“Gently rub the infant’s back.”
“Establish eye contact with the infant.”
“Gently stretch the arms and legs of the infant.”
“Gently rub the infant’s back.”
