Pediatric HESI Test Bank

Correct Answer: A

Rationale: The correct answer is A: Risk for impaired skin integrity due to cast and location. When caring for a child with a long-leg hip spica cast, the priority nursing diagnosis is the risk for impaired skin integrity. This is because the child's limited mobility and the pressure from the cast can lead to skin breakdown and complications. Choice B is incorrect as while education is essential, it is not the priority when immediate physical risks are present. Choice C is incorrect because while immobility can impact development, the immediate concern is preventing complications from the cast. Choice D is incorrect as it focuses on self-care deficits rather than the physical risk of skin integrity issues.

Correct Answer: A

Rationale: The priority nursing diagnosis for a newborn with Down syndrome is often related to feeding difficulties due to hypotonia, making imbalanced nutrition the primary concern. Hypotonia, or poor muscle tone, can lead to challenges with feeding and, subsequently, affect the baby's nutritional intake. While choices B, C, and D may also be concerns for a child with Down syndrome, addressing the immediate need for adequate nutrition takes precedence to ensure the infant's well-being and growth.

Correct Answer: C

Rationale: The correct hematocrit range for a healthy 12-month-old infant is between 37% to 47%. At this age, this range reflects the normal blood volume and red blood cell (RBC) levels in infants. Choice A (19% to 32%) is too low for a healthy hematocrit level in a 12-month-old. Choice B (29% to 41%) is also below the typical range for a 12-month-old. Choice D (42% to 69%) includes an upper limit that is higher than expected for a healthy infant, making it an incorrect option.

Correct Answer: A

Rationale: Tachypnea is an early sign of congestive heart failure that nurses should recognize. Tachypnea refers to rapid breathing, which can be an indication of the body's attempt to compensate for decreased cardiac output in congestive heart failure. Bradycardia (choice B) is a slow heart rate and is not typically associated with congestive heart failure. Inability to sweat (choice C) and increased urinary output (choice D) are not specific early signs of congestive heart failure and are not typically recognized as such.

Correct Answer: C

Rationale: The correct answer is C: Right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding aorta are the cardiac defects associated with Tetralogy of Fallot. In Tetralogy of Fallot, these specific abnormalities contribute to the classic features of the condition. Choice A is incorrect as it includes mitral valve stenosis, which is not typically part of Tetralogy of Fallot. Choice B describes transposition of the great arteries, not Tetralogy of Fallot. Choice D mentions an altered connection between the pulmonary artery and the aorta, which is not a defining characteristic of Tetralogy of Fallot.