Pediatric HESI Test Bank

Correct Answer: C

Rationale: Administering antibiotics is a crucial nursing intervention after a tonsillectomy because it helps prevent infections, which are a common postoperative complication. Encouraging deep breathing exercises (Choice A) is also important for promoting lung expansion and preventing respiratory complications. Encouraging the child to eat (Choice B) may not be appropriate immediately after a tonsillectomy due to the risk of throat irritation and discomfort. Applying ice to the throat (Choice D) is generally not recommended post-tonsillectomy as it may cause vasoconstriction and hinder the healing process.

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: D

Rationale: In a 3-year-old child presenting with sudden respiratory distress and no history of recent illnesses or fever, foreign body airway obstruction should be suspected. Foreign body airway obstruction commonly leads to acute respiratory distress without preceding symptoms. Croup (Choice A) typically presents with a barking cough and stridor. Epiglottitis (Choice B) often presents with high fever, drooling, and a muffled voice. Lower respiratory infection (Choice C) may manifest with symptoms such as cough, fever, and respiratory distress, but the sudden onset without fever or recent illness suggests a more acute event like foreign body airway obstruction.

Correct Answer: C

Rationale: The correct answer is C. In type 2 diabetes mellitus, excessive thirst (polydipsia) is a common symptom due to high blood glucose levels. This results in the patient feeling unable to drink enough water to satisfy their thirst. The other options are incorrect because a recent 'cold or flu' (choice A) is not directly related to diabetes mellitus, decreased blood pressure (choice B) is not a typical finding in uncontrolled diabetes, and Kussmaul breathing (choice D) is associated with diabetic ketoacidosis, which is more common in type 1 diabetes mellitus.

Correct Answer: A

Rationale: Tachypnea, which refers to rapid breathing, is an early sign of congestive heart failure. In heart failure, the heart's inability to pump efficiently can lead to fluid accumulation in the lungs, causing the child to breathe faster to try to compensate for the decreased oxygen exchange. Bradycardia (slow heart rate) is not typically associated with congestive heart failure; instead, it may indicate a different issue. Inability to sweat is not a common early sign of congestive heart failure. Increased urinary output is not a typical early sign of congestive heart failure; instead, it may be a sign of other conditions like diabetes or kidney issues.