HESI/SAUNDERS ONLINE REVIEW FOR THE NCLEX-RN
EXAMINATION (1 YEAR) QUESTIONS AND ANSWERS
100% CORRECT!!
,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 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
EXAMINATION (1 YEAR) QUESTIONS AND ANSWERS
100% CORRECT!!
,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 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
