HESI/SAUNDERS NCLEX EXAM |ACTUAL
QUESTIONS AND VERIFIED ANSWERS|BRAND NEW
2026-2027 UPDATE|GRADED A+
Question 1
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
CORRECT 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.
Question 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 the
client? Select all that apply.
1
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,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
CORRECT 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.
Question 3
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)
CORRECT 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
2
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, 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).
Question 4
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
CORRECT 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.
Question 5
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."
3
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, 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."
CORRECT 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.
Question 6
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
CORRECT 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.
Question 7
A client with a basilar skull fracture has clear fluid leaking from the ears. The nurse should:
4
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QUESTIONS AND VERIFIED ANSWERS|BRAND NEW
2026-2027 UPDATE|GRADED A+
Question 1
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
CORRECT 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.
Question 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 the
client? Select all that apply.
1
@https://www.stuvia.com/user/thestudyvault
,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
CORRECT 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.
Question 3
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)
CORRECT 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
2
@https://www.stuvia.com/user/thestudyvault
, 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).
Question 4
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
CORRECT 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.
Question 5
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."
3
@https://www.stuvia.com/user/thestudyvault
, 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."
CORRECT 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.
Question 6
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
CORRECT 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.
Question 7
A client with a basilar skull fracture has clear fluid leaking from the ears. The nurse should:
4
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