Pediatric HESI

Correct Answer: A

Rationale: Fussiness and low-grade fever are common side effects of immunizations in infants and usually resolve on their own. It is important for the nurse to educate the mother about these expected reactions to help ease her concerns. Immediate evaluation or giving aspirin to an infant for fever is not necessary or safe, as aspirin can be harmful to infants.

Correct Answer: B

Rationale: Measles is an airborne infection, so placing the child in airborne isolation is crucial to prevent the spread of the virus to others. Airborne isolation precautions help contain infectious respiratory droplets and reduce the risk of transmission to healthcare workers, other patients, and visitors.

Correct Answer: C

Rationale: After completing the chemotherapy infusion via the implanted medication port, the nurse should flush the mediport with saline and heparin solution. This action helps prevent clot formation in the port, ensuring its patency for future use and reducing the risk of complications associated with catheter occlusion.

Correct Answer: C

Rationale: A set of cloth and hand puppets is safe and developmentally appropriate for a 3-year-old with a spica cast.

Correct Answer: B

Rationale: Coarctation of the aorta causes narrowing of the aorta, reducing blood flow to the lower extremities, leading to higher blood pressure in the arms.