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HESI/Saunders Online Review for the NCLEX-RN Examination (1 Year) Latest Update A+ 2024
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HESI/Saunders Online Review for the NCLEX-RN Examination (1 Year) Latest Update A+ 2024
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HESI/Saunders Online Review for the NCLEX-RNExamination (1 Year) Latest Update
A nurse is assigned to care for a client with chronic renal failure who is receiving
hemodialysis through an internal AV fistula in the right arm. Which of the following
nursing interventions are appropriate when caring for this client? (Select all that apply.)
A) Checking the radial pulse in the right extremity
B) Obtaining blood pressure in the left arm
C) Drawing predialysis blood specimens from the left arm D) Checking the area over the
AV fistula for a bruit and thrill each shift
E) Applying a pressure dressing over the site after each dialysis treatment
F) Administering IV fluids through the venous site of the AV fistula as needed - Answer
Answer(s): A,B,C,D
Rationale: The function of an internal AV fistula requires several precautions to be
taken. The nurse checks the fistula and the distal portion of the extremity for adequate
circulation, listening or feeling for a bruit and a thrill 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. The extremity bearing the AV fistula should avoid
venipuncture. Blood is never withdrawn from the AV fistula and the AV fistula is never
used for the infusion of IV fluids. The AV fistula site is not dressed with a pressure
dressing after dialysis.
Guillain-Barré Syndrome
A nurse is evaluating outcomes for a client who has been diagnosed with Guillain-Barré
syndrome. Which of the following outcomes does the nurse recognize as an optimal
respiratory outcome for the client? Choose 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. These ABG results reported 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 who works on the telemetry unit is caring for a client who has had a myocardial
infarction and is connected to a cardiac monitor. The nurse is monitoring the client's
cardiac rhythm and notices the following rhythm. Which of the following nursing
interventions should the nurse take?
(Rhythm is continuous up and down in pic)
A) Activate the rapid response team
B) Prepare the client for cardioversion
C) Ask the client to bear down and cough
D) Prepare to administer diltiazem (Cardiazem) - Answer Answer: A
Rationale: This rhythm strip represents ventricular fibrillation (VF). A client who has
experienced a myocardial infarction is at great risk for VF. With the onset of VF, the
client feels faint, then immediately becomes unconscious, pulseless, and apneic. No
blood pressure is detected and no heart sounds can be heard. Goals of treatment To
terminate VF promptly and convert it to an organized rhythm Because defibrillation is
the immediate treatment, the nurse would need to activate the rapid response team and
begin cardiopulmonary resuscitation The client would not be able to bear down or
cough. Cardioversion is the delivery of a synchronized countershock and may be
performed electively for unstable ventricular or supraventricular tachydysrhythmias or
for stable tachydysrhythmias resistant to medical therapies such as the administration
of diltiazem (Cardiazem).
A nurse develops a plan of care for a client who has been diagnosed with a spinal cord
injury and includes interventions that are directed at the prevention of autonomic
dysreflexia (hyperreflexia). The nurse should include which of the following
interventions in the plan of care to prevent this complication?
A) The fan running in the client's room
B) Linens smooth without wrinkles under the client
C) Bladder catheterization limited to once every 12 hours
,D) Withholding the administration of enemas and rectal suppositories - Answer Answer:
B
Rationale: The most common precipitating causes of autonomic dysreflexia are a
distended bladder and impacted stool in the rectum. Straight catheterization should be
done every 4 to 6 hours, and the Foley catheter should be checked frequently to avoid
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 teaches a client who has been placed in a halo device to treat a cervical
fracture about how to care for himself at home. Which client statement below identifies
that the client needs additional teaching?
A) "I need to increase my fluids and add fiber to my diet."
B) "I need to cut my food up into small pieces to eat."
C) "I need to put powder under the vest twice daily so it is not too sweaty."
D) "I need to look at the sites of the pins daily and watch for infection." Answer Answer:
C
Rationale: The skin under the lambs-wool liner should be cleansed daily to avoid rashes
or sores. Powder or lotions are best used sparingly or not at all because they can cake
and cause 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 be taught to sip liquids through a straw.
The pin sites should be checked daily for any sign of infection.
CN: Coordination of Care;
IN: Physiological Integrity
Client Need: Safe and Effective Care Environment
A nurse is caring for a client with ICP. The nurse should position the client in which of
the following positions?
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 is positioned to keep the head in a neutral
midline position. The nurse is responsible for ensuring that anyone caring for the client
maintains proper positioning. The client should avoid neck flexion or extension and neck
rotation from side to side. The head of the bed is elevated to 30 to 45 degrees. Use of
proper positioning promotes venous drainage from the head to assist in maintaining low
ICP.
A client with a basilar skull fracture presents with leakage of clear fluid from the ears.
The nurse should:
A) Check the clear fluid for the presence of protein
B) Check the clear fluid for the presence of glucose
C) Lightly pack cotton balls or dry gauze in the ears
D) Use an otoscope to examine the tympanic membrane for rupture - Answer Answer: B
Rationale: Basilar skull fracture may be associated with leakage of cerebrospinal fluid
(CSF) from the ears or nose. CSF can be identified on dressing material from other body
fluids because it forms bloody and yellow concentric rings, a finding called the halo
sign. It also contains glucose. CSF does not contain protein. The presence of CSF
indicates that the integrity of the cranium has been compromised. Therefore, it is unsafe
to place cotton balls, gauze, or an otoscope in the ear because the client is at risk for
infection.
A nurse is caring for a client who has undergone cardioversion. Which of the following
actions is the nurse's priority after this procedure?
A) Oxygen administration
B) Blood pressure monitoring
C) Administering antidysrhythmic medications
D) Monitoring the client's level of consciousness - Answer Answer: A
Rationale: Nursing responsibilities after cardioversion include maintenance of a patent
airway, oxygen administration, assessment of vital signs and level of consciousness,
and detection of dysrhythmias. The priority nursing intervention here is administering
oxygen.
A patient is diagnosed with diabetes mellitus and is scheduled to undergo blood drawing
for determination of the glycosylated hemoglobin (HbA1C) level. The patient asks the
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