A 2-year-old boy with short bowel syndrome has progressed to receiving enteral feedings only. Today his stools are occurring more frequently and have a more liquid consistency. His temperature is 102.2°F and he has vomited twice in the past four hours. Which assessment finding indicates that the child is becoming dehydrated?

Questions 52

HESI RN

HESI RN Test Bank

HESI RN CAT Exit Exam Questions

Question 1 of 5

A 2-year-old boy with short bowel syndrome has progressed to receiving enteral feedings only. Today his stools are occurring more frequently and have a more liquid consistency. His temperature is 102.2°F and he has vomited twice in the past four hours. Which assessment finding indicates that the child is becoming dehydrated?

Correct Answer: C

Rationale: Step 1: Elevated urine specific gravity indicates increased concentration of urine, a sign of dehydration. Step 2: In dehydration, the body conserves water, leading to concentrated urine. Step 3: The child's symptoms (increased stools, liquid consistency, fever, vomiting) suggest dehydration. Step 4: Other choices (A: occult blood, B: distention, D: hyperactive bowel sounds) are not specific to dehydration. Summary: Elevated urine specific gravity is key as it directly reflects dehydration, unlike the other choices which are not specific indicators of dehydration.

Question 2 of 5

In preparing to administer a scheduled dose of intravenous furosemide (Lasix) to a client with heart failure, the nurse notes that the client's B-Type Naturetic peptide (BNP) is elevated. What action should the nurse take?

Correct Answer: C

Rationale: The correct action is to administer the dose of furosemide as scheduled (Choice C) because an elevated BNP level indicates increased fluid volume and pressure in the heart. Furosemide is a diuretic that helps reduce fluid overload in heart failure patients, which can alleviate symptoms and improve cardiac function. Holding the dose (Choice D) could delay necessary treatment, potentially worsening the patient's condition. Measuring oxygen saturation (Choice A) is important but not the immediate priority in this situation. Administering nitroglycerin (Choice B) is not appropriate as it is used for chest pain related to angina, not for treating elevated BNP levels in heart failure.

Question 3 of 5

A client with an electrical burn on the forearm asks the nurse why there is no feeling of pain from the burn. During the dressing change, the nurse determines that the burn is dry, waxy, and white. What information should the nurse provide this client?

Correct Answer: C

Rationale: The correct answer is C because full-thickness burns destroy nerve endings, resulting in the absence of pain sensation. The dry, waxy, and white appearance indicates tissue destruction extending through the epidermis and dermis. Choices A and D are incorrect because dry, waxy, and white appearance signifies a deeper burn, not a minor or superficial burn, and second-degree burns typically involve pain sensation. Choice B is incorrect as nerve compression does not explain the lack of pain sensation in a full-thickness burn.

Question 4 of 5

A client with type 2 diabetes mellitus is admitted for antibiotic treatment of a leg ulcer. Which signs and symptoms, indicative of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), should the nurse report to the healthcare provider? (Select one that doesn't apply.)

Correct Answer: C

Rationale: The correct answer is C: Presence of uremic frost. HHNS is characterized by severe hyperglycemia leading to osmotic diuresis and dehydration, not uremia. A: Increased heart rate is a non-specific sign of stress. B: Visual disturbances can be seen in diabetic retinopathy but are not specific to HHNS. D: Decreased mentation is common in HHNS due to severe dehydration and hyperglycemia leading to altered mental status.

Question 5 of 5

The client diagnosed with a right fractured femur has skeletal traction applied to the right femur. Which interventions should the nurse implement?

Correct Answer: D

Rationale: The correct answer is D: Maintain skeletal pin sites and assess for signs of infection. This is important to prevent complications like infection, which can be severe. The nurse should regularly assess the pin sites for redness, swelling, or discharge. This intervention ensures early detection and prompt treatment of any signs of infection, reducing the risk of serious complications. Choice A is incorrect because performing passive range of motion to the right leg may disrupt the traction and interfere with the healing process. Choice B is incorrect because removing skeletal weights every shift can lead to loss of traction, compromising the fracture alignment and healing process. Choice C is incorrect because turning the client frequently from prone to supine positions may also disrupt the traction and increase the risk of complications.

Access More Questions!

HESI RN Basic


$89/ 30 days

HESI RN Premium


$150/ 90 days

Similar Questions