HESI/Saunders Review Exam Questions And Answers 100% Pass
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HESI/Saunders
HESI/Saunders Review Exam Questions And
Answers 100% Pass
A nurse is assigned to care for a client with chronic renal failure who is undergoing hemodialysis through
an internal arteriovenous (AV) fistula in the right arm. Which of the following interventions should the
nurse implement in caring...
HESI/Saunders Review Exam Questions And
Answers 100% Pass
A nurse is assigned to care for a client with chronic renal failure who is undergoing hemodialysis through
an internal arteriovenous (AV) fistula in the right arm. Which of the following interventions should the
nurse implement in caring for the client? Select all that apply.
A) Assessing the radial pulse in the right extremity
B) Using the left arm to take blood pressure readings
C) Drawing predialysis blood specimens from the left arm D) Assessing the area over the AV fistula for a
bruit and thrill each shift
E) Placing a pressure dressing over the site after each dialysis treatment
F) Administering intravenous (IV) fluids through the venous site of the AV fistula as needed -
answer✔Answer(s): A,B,C,D
Rationale: Several precautions must be observed to ensure the function of an internal AV fistula. The
nurse assesses the fistula, and the distal portion of the extremity, for adequate circulation; checks for a
bruit and a thrill by means of auscultation or palpation over the access site; monitors the radial pulse in
the extremity; and avoids taking blood pressure readings or drawing blood from the arm with the AV
fistula. Venipuncture is avoided in the extremity bearing the AV fistula. Blood is never drawn from the
AV fistula, and the AV fistula is not used for the administration of IV fluids. The AV fistula site is not
covered with a pressure dressing after dialysis.
A nurse is evaluating outcomes for a client with Guillain-Barré syndrome. Which of the following
outcomes does the nurse recognize as optimal respiratory outcomes for the client? Select all that apply.
A) Normal deep tendon reflexes
B) Improved skeletal muscle tone
C) Absence of paresthesias in the lower extremities
D) Clear sounds in the lower lung fields bilaterally
E) Po2 of 85% and Pco2 of 40 mm Hg - answer✔Answer(s): D,E
Rationale: Satisfactory respiratory outcomes include clear breath sounds on auscultation, clear
mentation, spontaneous breathing, normal vital capacity, and normal arterial blood gases. The ABG
results listed here — a Po2 of 85% and a Pco2 of 40 mm Hg — are normal. The presence of normal deep
tendon reflexes, improved skeletal muscle tone, and absence of paresthesias in the lower extremities
reflect improvement in the symptoms associated with Guillain-Barré but are not specific to a respiratory
outcome.
A nurse on the telemetry unit is caring for a client who has had a myocardial infarction and is now
attached to a cardiac monitor. The nurse, monitoring the client's cardiac rhythm, notes the rhythm
depicted in the image. Which of the following nursing actions should the nurse take?
(Rhythm is continuous up and down in pic)
A) Calling the rapid response team
B) Preparing the client for cardioversion
C) Asking the client to bear down and cough
D) Preparing to administer diltiazem (Cardiazem) - answer✔Answer: A
Rationale: This pattern indicates ventricular fibrillation (VF). Clients who have sustained a myocardial
infarction are at great risk for VF. With the onset of VF the client feels faint, then immediately loses
consciousness and becomes pulseless and apneic. There is no blood pressure, and heart sounds are
absent. The goals of treatment are to terminate VF promptly and convert it to an organized rhythm.
Because defibrillation is the immediate treatment, the nurse must call the rapid response team and
initiate cardiopulmonary resuscitation. The client would not be able to bear down or cough.
Cardioversion is a synchronized countershock that may be performed in emergencies for unstable
ventricular or supraventricular tachydysrhythmias or electively for stable tachydysrhythmias that are
resistant to medical therapies such as the administration of diltiazem (Cardiazem).
A nurse developing a plan of care for a client with a spinal cord injury includes measures to prevent
autonomic dysreflexia (hyperreflexia). Which of the following interventions does the nurse incorporate
into the plan to prevent this complication?
A) Keeping a fan running in the client's room
B) Keeping the linens wrinkle-free under the client
C) Limiting bladder catheterization to once every 12 hours
D) Avoiding the administration of enemas and rectal suppositories - answer✔Answer: B
Rationale: The most frequent causes of autonomic dysreflexia are a distended bladder and impacted
feces in the rectum. Straight catheterization should be performed every 4 to 6 hours, and the Foley
catheter should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction
are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the
skin by tactile, thermal, or painful stimuli. The nurse renders care in such a way as to minimize risk in
these areas.
A nurse provides home care instructions to a client who has been fitted with a halo device to treat a
cervical fracture. Which statement by the client indicates the need for further instruction?
A) "I need to get more fluids and fiber into my diet."
B) "I should cut my food into small pieces before I eat."
C) "I need to put powder under the vest twice a day to prevent sweating."
D) "I have to check the pin sites every day and watch for signs of infection." - answer✔Answer: C
Rationale: The client should cleanse the skin under the lambs-wool liner each day to prevent rashes or
sores. Powder or lotions should be used only sparingly or not at all because they may cake, resulting in
skin irritation. The client should increase intake of fluid and fiber to help prevent constipation. Food
should be cut into small pieces to facilitate chewing and swallowing. The client should also use a straw
for drinking. The pin sites should be checked daily for signs of infection.
A nurse is caring for client with increased intracranial pressure (ICP). In which position should the nurse
maintain the client?
A) Supine, with the head extended
B) Side-lying, with the neck flexed
C) Supine, with the head turned to the side
D) Head midline and elevated 30 to 45 degrees - answer✔Answer: D
Rationale: The client with increased ICP should be positioned with the head in a neutral midline position.
It is the responsibility of the nurse to ensure that all those delivering care to the client maintain the
proper positioning. The client should avoid flexing or extending the neck or turning the neck side to side.
The head of the bed should be raised to 30 to 45 degrees. Use of proper positioning promotes venous
drainage from the cranium to keep ICP down.
A client with a basilar skull fracture has clear fluid leaking from the ears. The nurse should:
A) Assess the clear fluid for protein
B) Check the clear fluid for the presence of glucose
C) Place cotton balls or dry gauze loosely in the ears
D) Use an otoscope to assess the tympanic membrane for rupture - answer✔Answer: B
Rationale: Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull
fracture. CSF can be distinguished from other body fluids because it will separate into bloody and yellow
concentric rings on dressing material, a phenomenon referred to as the halo sign. It also tests positive
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