,Contents
HESI/Saunders Review .............................................................................................................2
HESI/Saunders Online Review .......................................................................................... 211
MOST TESTED FOR HESI/Saunders Review..................................................................... 263
MOST TESTED FOR HESI/Saunders ONLINE Review ............................................................... 320
HESI/Saunders Review
1.
A nurse is assigned to care for a client with chronic renal failure who is undergoing hemodialysis
through an internal arteriovenous (AV) fistula located in the right arm. Which of the following
interventions should the nurse implement in caring for this 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
CORRECT ANS: a, b, c, d
EXPERT RATIONALE
An internal arteriovenous (AV) fistula is a surgically created connection between an artery and a
vein, typically in the arm, to provide reliable vascular access for hemodialysis. Meticulous care of
this access site is paramount to ensure its patency and prevent complications. The nurse must
assess for adequate circulation distal to the fistula by monitoring the radial pulse in the affected
extremity (a). The patency of the fistula itself is evaluated by auscultating for a bruit (a
swooshing sound) and palpating for a thrill (a buzzing vibration) over the site each shift (d). To
prevent damage to the fistula, all blood pressure measurements (b) and venipunctures for blood
draws (c) must be performed on the contralateral (opposite) arm. The AV fistula is strictly
reserved for hemodialysis access; it must never be used for routine IV fluid administration or
blood draws (f). A pressure dressing is not applied over the AV fistula site after dialysis; instead, a
sterile gauze dressing is used to apply gentle pressure until hemostasis is achieved, after which a
light dressing may be applied (e).
DIF: Cognitive Level: Analyze (Application)
REF: Renal Disorders / Hemodialysis
,OBJ: Identify appropriate interventions for AV fistula care
TOP: Safety / Assessment
MSC: NCLEX: Physiological Integrity – Reduction of Risk Potential
2.
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 this 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 breath sounds in the lower lung fields bilaterally
e. PaO₂ of 85 mm Hg and PaCO₂ of 40 mm Hg
CORRECT ANS: d, e
EXPERT RATIONALE
Guillain-Barré syndrome is an acute, autoimmune, demyelinating polyneuropathy that can cause
progressive ascending paralysis, including respiratory muscle weakness. Optimal respiratory
outcomes indicate that the client's respiratory status is stable and uncompromised. Clear breath
sounds bilaterally (d) are indicative of good air exchange and the absence of secretions or
atelectasis. Normal arterial blood gas (ABG) values, such as a PaO₂ of 85 mm Hg and a PaCO₂ of
40 mm Hg (e), reflect adequate oxygenation and ventilation. Options a, b, and c describe
improvement in neurological symptoms (deep tendon reflexes, muscle tone, and sensory
changes) associated with the disease, but they are not specifically indicators of respiratory
function.
DIF: Cognitive Level: Evaluate (Application)
REF: Neurological Disorders / Guillain-Barré Syndrome
OBJ: Evaluate optimal respiratory outcomes
TOP: Evaluation
MSC: NCLEX: Physiological Integrity – Physiological Adaptation
3.
A nurse on the telemetry unit is caring for a client who has experienced 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 (a chaotic, irregular waveform with no discernible P
waves or QRS complexes). Which of the following nursing actions should the nurse take?
, 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)
CORRECT ANS: a
EXPERT RATIONALE
The cardiac rhythm described is characteristic of ventricular fibrillation (VF), a life-threatening
dysrhythmia that results in no effective cardiac output. Clients who have sustained a myocardial
infarction are at high risk for VF. This rhythm requires immediate intervention, as the client will
rapidly lose consciousness, become pulseless, and experience apnea. The priority action is to call
the rapid response team (or code team) and initiate cardiopulmonary resuscitation (CPR) while
preparing for defibrillation, which is the definitive treatment for VF. The client would be
unresponsive and unable to bear down or cough (c). Cardioversion (b) is a synchronized shock
used for unstable tachydysrhythmias with a discernible QRS complex, not for VF. Diltiazem (d) is a
calcium channel blocker used for atrial dysrhythmias, not VF.
DIF: Cognitive Level: Analyze (Application)
REF: Cardiac Disorders / Dysrhythmias
OBJ: Identify appropriate treatment for ventricular fibrillation
TOP: Safety / Implementation
MSC: NCLEX: Physiological Integrity – Reduction of Risk Potential
4.
A nurse is developing a plan of care for a client with a spinal cord injury. The plan includes
measures to prevent autonomic dysreflexia (hyperreflexia). Which of the following interventions
does the nurse incorporate into the plan to prevent this life-threatening 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
CORRECT ANS: b
EXPERT RATIONALE
Autonomic dysreflexia is a potentially fatal complication of spinal cord injury, typically occurring
at or above the T6 level. It is characterized by a sudden, severe elevation in blood pressure in
response to a noxious stimulus below the level of injury. The most common triggers are a
distended bladder or impacted feces. Preventive measures focus on avoiding these stimuli.
HESI/Saunders Review .............................................................................................................2
HESI/Saunders Online Review .......................................................................................... 211
MOST TESTED FOR HESI/Saunders Review..................................................................... 263
MOST TESTED FOR HESI/Saunders ONLINE Review ............................................................... 320
HESI/Saunders Review
1.
A nurse is assigned to care for a client with chronic renal failure who is undergoing hemodialysis
through an internal arteriovenous (AV) fistula located in the right arm. Which of the following
interventions should the nurse implement in caring for this 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
CORRECT ANS: a, b, c, d
EXPERT RATIONALE
An internal arteriovenous (AV) fistula is a surgically created connection between an artery and a
vein, typically in the arm, to provide reliable vascular access for hemodialysis. Meticulous care of
this access site is paramount to ensure its patency and prevent complications. The nurse must
assess for adequate circulation distal to the fistula by monitoring the radial pulse in the affected
extremity (a). The patency of the fistula itself is evaluated by auscultating for a bruit (a
swooshing sound) and palpating for a thrill (a buzzing vibration) over the site each shift (d). To
prevent damage to the fistula, all blood pressure measurements (b) and venipunctures for blood
draws (c) must be performed on the contralateral (opposite) arm. The AV fistula is strictly
reserved for hemodialysis access; it must never be used for routine IV fluid administration or
blood draws (f). A pressure dressing is not applied over the AV fistula site after dialysis; instead, a
sterile gauze dressing is used to apply gentle pressure until hemostasis is achieved, after which a
light dressing may be applied (e).
DIF: Cognitive Level: Analyze (Application)
REF: Renal Disorders / Hemodialysis
,OBJ: Identify appropriate interventions for AV fistula care
TOP: Safety / Assessment
MSC: NCLEX: Physiological Integrity – Reduction of Risk Potential
2.
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 this 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 breath sounds in the lower lung fields bilaterally
e. PaO₂ of 85 mm Hg and PaCO₂ of 40 mm Hg
CORRECT ANS: d, e
EXPERT RATIONALE
Guillain-Barré syndrome is an acute, autoimmune, demyelinating polyneuropathy that can cause
progressive ascending paralysis, including respiratory muscle weakness. Optimal respiratory
outcomes indicate that the client's respiratory status is stable and uncompromised. Clear breath
sounds bilaterally (d) are indicative of good air exchange and the absence of secretions or
atelectasis. Normal arterial blood gas (ABG) values, such as a PaO₂ of 85 mm Hg and a PaCO₂ of
40 mm Hg (e), reflect adequate oxygenation and ventilation. Options a, b, and c describe
improvement in neurological symptoms (deep tendon reflexes, muscle tone, and sensory
changes) associated with the disease, but they are not specifically indicators of respiratory
function.
DIF: Cognitive Level: Evaluate (Application)
REF: Neurological Disorders / Guillain-Barré Syndrome
OBJ: Evaluate optimal respiratory outcomes
TOP: Evaluation
MSC: NCLEX: Physiological Integrity – Physiological Adaptation
3.
A nurse on the telemetry unit is caring for a client who has experienced 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 (a chaotic, irregular waveform with no discernible P
waves or QRS complexes). Which of the following nursing actions should the nurse take?
, 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)
CORRECT ANS: a
EXPERT RATIONALE
The cardiac rhythm described is characteristic of ventricular fibrillation (VF), a life-threatening
dysrhythmia that results in no effective cardiac output. Clients who have sustained a myocardial
infarction are at high risk for VF. This rhythm requires immediate intervention, as the client will
rapidly lose consciousness, become pulseless, and experience apnea. The priority action is to call
the rapid response team (or code team) and initiate cardiopulmonary resuscitation (CPR) while
preparing for defibrillation, which is the definitive treatment for VF. The client would be
unresponsive and unable to bear down or cough (c). Cardioversion (b) is a synchronized shock
used for unstable tachydysrhythmias with a discernible QRS complex, not for VF. Diltiazem (d) is a
calcium channel blocker used for atrial dysrhythmias, not VF.
DIF: Cognitive Level: Analyze (Application)
REF: Cardiac Disorders / Dysrhythmias
OBJ: Identify appropriate treatment for ventricular fibrillation
TOP: Safety / Implementation
MSC: NCLEX: Physiological Integrity – Reduction of Risk Potential
4.
A nurse is developing a plan of care for a client with a spinal cord injury. The plan includes
measures to prevent autonomic dysreflexia (hyperreflexia). Which of the following interventions
does the nurse incorporate into the plan to prevent this life-threatening 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
CORRECT ANS: b
EXPERT RATIONALE
Autonomic dysreflexia is a potentially fatal complication of spinal cord injury, typically occurring
at or above the T6 level. It is characterized by a sudden, severe elevation in blood pressure in
response to a noxious stimulus below the level of injury. The most common triggers are a
distended bladder or impacted feces. Preventive measures focus on avoiding these stimuli.
