Pediatric HESI Test Bank

Correct Answer: D

Rationale: In a 3-year-old child presenting with sudden respiratory distress without fever or recent illness, the most likely cause is a foreign body airway obstruction. Foreign body airway obstruction can lead to a sudden onset of respiratory distress as it blocks the air passage. Croup typically presents with a barking cough and stridor, often preceded by a viral illness. Epiglottitis is characterized by high fever, drooling, and a muffled voice. Lower respiratory infections usually present with symptoms such as cough, fever, and chest congestion. Therefore, in this case, the absence of recent illness or fever makes foreign body airway obstruction the most likely cause of the respiratory distress.

Correct Answer: B

Rationale: Upright positioning is the optimal intervention to promote maximum chest expansion in a child with Duchenne muscular dystrophy. By placing the child in an upright position, gravity can assist in expanding the chest cavity, facilitating better lung expansion and improving breathing efficiency. Deep-breathing exercises may be beneficial but are not as effective in maximizing chest expansion as upright positioning. Coughing and chest percussion focus more on airway clearance and are not directly aimed at promoting chest expansion.

Correct Answer: D

Rationale: The correct priority nursing action in this situation is to administer the prescribed dose of rapid-acting insulin. Rapid-acting insulin is necessary to help lower the elevated blood glucose level quickly, thereby preventing potential complications of hyperglycemia. Encouraging exercise, obtaining a glucometer reading, or suggesting consumption of complex carbohydrates like cheese may not address the immediate need to bring down the high blood glucose level effectively. Exercise could potentially raise blood glucose levels, obtaining a glucometer reading may delay necessary treatment, and consuming complex carbohydrates can further elevate blood glucose levels in this scenario.

Correct Answer: C

Rationale: Administering antibiotics is crucial post-tonsillectomy to prevent infection, as the surgical site is susceptible to bacterial growth. Encouraging deep breathing exercises can also be beneficial for lung expansion and preventing respiratory complications. However, administering antibiotics takes precedence as it directly addresses the risk of infection. Encouraging the child to eat may not be appropriate immediately post-tonsillectomy due to the risk of throat irritation and potential discomfort. Applying ice to the throat is typically not recommended after a tonsillectomy, as it may constrict blood vessels and hinder the healing process.

Correct Answer: C

Rationale: Discussing any other observed behaviors can help identify patterns or potential issues, which is crucial for assessing the infant's overall well-being. Option A about accidents and prevention is not pertinent to the situation described. Option B regarding playtime with other children does not address the infant's behavior and potential causes. Option D about food and vitamins is not relevant to the presented scenario and the observed behavior of the infant.