After corrective surgery for hypertrophic pyloric stenosis (HPS) is completed, and the infant is returned to the pediatric unit with an IV infusion in place, what is the priority nursing action?

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Pediatrics HESI 2023 Questions

Question 1 of 5

After corrective surgery for hypertrophic pyloric stenosis (HPS) is completed, and the infant is returned to the pediatric unit with an IV infusion in place, what is the priority nursing action?

Correct Answer: C

Rationale: The priority nursing action after corrective surgery for hypertrophic pyloric stenosis (HPS) is to assess the IV site for infiltration. This is crucial as it ensures proper fluid administration and prevents complications such as phlebitis or infiltration-related tissue damage. Applying restraints (Choice A) would not be appropriate in this situation as it is not related to the immediate post-operative care of an infant with an IV infusion. Administering a mild sedative (Choice B) is not indicated as the primary concern post-surgery is monitoring the IV site and the infant's response to the surgery. Attaching the nasogastric tube to wall suction (Choice D) is not the priority at this time, as assessing the IV site takes precedence to prevent potential complications.

Question 2 of 5

The nurse has developed a plan of care for a 6-year-old with muscular dystrophy. He was recently injured when he fell out of bed at home. Which intervention would the nurse suggest to prevent further injury?

Correct Answer: D

Rationale: For a child with muscular dystrophy who fell out of bed, it is important to prevent further injuries. Using bed side rails when a caregiver is not present can help provide a safety measure and prevent falls. While continuous caregiver presence (choice B) may be ideal, it may not always be feasible. Recommending raising the bed's side rails throughout the day and night (choice A) may limit the child's mobility unnecessarily. Encouraging the use of a loose restraint (choice C) can be dangerous and may increase the risk of injury in case of a fall.

Question 3 of 5

The nurse is developing a teaching plan for a child who is to have his cast removed. What instruction would the nurse most likely include?

Correct Answer: C

Rationale: The correct instruction for the nurse to include in the teaching plan is to advise the child to soak the area in warm water every day. Soaking the area in warm water helps to gently remove dead skin without causing irritation, facilitating the safe and comfortable removal of the cast. Applying petroleum jelly (Choice A) may not be necessary and could interfere with the cast removal process. Rubbing the skin vigorously (Choice B) can lead to skin damage and should be avoided. Washing the skin with diluted peroxide and water (Choice D) is not recommended as peroxide can be irritating to the skin and may not aid in cast removal.

Question 4 of 5

An 18-month-old was brought to the emergency department by her mother, who states, 'I think she broke her arm.' The child is sent for a radiograph to confirm the fracture. Additional assessment of the child leads the nurse to suspect possible child abuse. Which type of fracture would the radiograph most likely reveal?

Correct Answer: C

Rationale: A spiral fracture is a type of fracture often associated with twisting injuries and can raise suspicion of child abuse. This type of fracture is caused by a twisting force applied to a bone. Plastic deformity is not typically associated with fractures but refers to the ability of a material to change shape and retain that shape. A buckle fracture, also known as a torus fracture, is an incomplete break in a bone commonly seen in children. A greenstick fracture is an incomplete fracture where the bone is bent and partially broken, more commonly seen in children due to their bone flexibility.

Question 5 of 5

.A nurse is caring for an infant whose vomiting is intractable. For what complication is it most important for the nurse to assess?

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

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