HESI Saunders Online Review for the NCLEX-
RN Examination Questions with 100% Correct
Answers
A client is receiving parenteral nutrition (PN) solution at 60 mL/hr by means of infusion pump
through a subclavian central line. The client calls the nurse and complains of difficulty breathing
and chest pain. The nurse notes that the client's pulse rate is increased, the blood pressure has
dropped, and oxygen saturation is 89%. Use the number 1 to denote the first action and the
number 4 the last.
~ Placing the client in lateral Trendelenburg position on the left side
~ Clamping the PN infusion catheter
~ Obtaining an electrocardiogram (ECG)
~ Notifying the physician - ✔️✔️The correct order is:
1) Clamping the PN infusion catheter
2) Placing the client in lateral Trendelenburg position on the left side
3) Notifying the physician
4) Obtaining an electrocardiogram (ECG)Rationale: One complication of subclavian central line
insertion is embolism, air or thrombus. Signs and symptoms include chest pain, dyspnea,
hypoxia, anxiety, tachycardia, and hypotension. On auscultation, the nurse would hear a loud
churning sound over the pericardium. If this sign is detected, the PN infusion catheter is
immediately clamped and the client placed in a lateral Trendelenburg position on the left side,
which helps trap the air in the apex of the ventricle and prevents its ejection into the
pulmonary arterial system. The physician would be notified. An ECG may be obtained, but this
would not be the immediate action.
A nurse is preparing to administer digoxin (Lanoxin) to a client with heart failure. On assessing
of the client, the nurse notes an apical pulse rate of 58 beats/min and the client complains of
anorexia and nausea. Which action should the nurse take first on the basis of these assessment
findings?
A) Contacting the physician
B) Administering an as-needed antiemetic
,C) Checking the most recent digoxin level
D) Administering the digoxin with an antacid - ✔️✔️Answer: C
Rationale: Anorexia and nausea are two of the symptoms most commonly associated with
digoxin toxicity. The nurse should withhold the digoxin until the physician has been consulted if
the pulse rate is slower than 60 beats/min, because bradycardia is also an indication of digoxin
toxicity. The nurse then checks the most recent digoxin level, which will provide additional data
to report to the physician — a key follow-up nursing action. The nurse would not administer an
antiemetic without further investigating the client's problem.
A nurse is assessing a client who has undergone radical neck dissection for the treatment of
cancer. The nurse hears this sound when auscultating over the trachea. On the basis of this
finding, the priority nursing action is to:
A) Contact the physician
B) Assess the client's pulse oximetry
C) Place the client in a supine position
D) Administer a nebulizer treatment with the use of a bronchodilator - ✔️✔️Answer: A
Rationale: The sound that the nurse hears is stridor. In the immediate postoperative period, the
nurse assesses the client for stridor, a high-pitched musical sound heard on inspiration during
auscultation over the trachea. This finding is reported immediately because it indicates airway
obstruction. The client is placed in the Fowler position to facilitate breathing and promote
comfort. Suctioning is performed to remove secretions that cannot be expectorated by the
client. Pulse oximetry may be performed, but this is not the priority of the options provided.
Administering a nebulizer treatment with a bronchodilator is not indicated at this time.
A nurse is caring for a hospitalized child with newly diagnosed type 1 diabetes mellitus who
received NPH and regular humulin insulin at 7:30 am. At 11 am the child suddenly complains of
dizziness, headache, and a shaky feeling. The nurse immediately:
A) Contacts the physician
B) Gives the child milk to drink
C) Arranges to have the child's lunch tray delivered early
D) Prepares to administer intravenous 5% dextrose solution - ✔️✔️Answer: B
,Rationale: Dizziness, headache, and a shaky feeling are signs of hypoglycemia. A blood glucose
reading will confirm the diagnosis and would be the initial action. However, because this is not
one of the options, the nurse would give the child milk to drink because of the child's history
and current symptoms indicating hypoglycemia. Other items used to treat hypoglycemia
include orange juice and hard candy. The nurse would prepare to administer intravenous 5%
dextrose solution if the child were not responsive enough to safely take oral fluids, but this is
not indicated in the question. Arranging to have the child's lunch tray delivered early is
inappropriate because the child should eat meals at basically the same time each day to
achieve the best control of the diabetes. Contacting the physician would not be the immediate
action.
A client with a diagnosis of preeclampsia suddenly begins to exhibit seizure activity. The first
action on the part of the nurse is:
A) Calling the physician
B) Inserting an oral airway
C) Turning the client on her side
D) Noting the time of the seizure - ✔️✔️Answer: C
Rationale: If seizure activity occurs, the nurse remains with the client and presses the
emergency bell for assistance. The client is turned on her side because a side-lying position
permits greater circulation through the placenta and helps prevent aspiration. The nurse then
notes the time and sequence of the seizure. The physician is notified that a seizure has
occurred, because this is an obstetric emergency associated with cerebral hemorrhage,
abruptio placentae, severe fetal hypoxia, and death. No object should be placed in the client's
mouth during a seizure. An airway may be inserted after the seizure, and the client's mouth and
nose are suctioned to prevent aspiration. Oxygen may be administered by way of face mask
during the seizure to increase oxygenation of the placenta and all maternal organs.
A nurse performs a bedside glucose test on a newborn infant whose mother has diabetes
mellitus and obtains a reading of 35 mg/dL. The nurse would first:
A) Ask the mother to breastfeed the newborn Incorrect
B) Bottle-feed the newborn with diluted glucose
C) Start an intravenous line for the administration of glucose
D) Ask the laboratory to perform a blood glucose test immediately - ✔️✔️Answer: D
, Rationale: The normal blood glucose level in a newborn is 40 mg/dL or higher. Glucose levels of
less than 40 to 45 mg/dL measured with bedside glucose screening should be reported and
verified in the laboratory. Although feeding is an intervention, the result of a bedside glucose
must be verified by the laboratory. Some infants need IV glucose to maintain glucose balance
and prevent damage to the brain.
A pregnant woman is being admitted to the maternity unit. The woman tells the nurse that she
felt a large gush of fluid from her vagina on the way to the hospital. The nurse detects a fetal
heart rate of 90 beats/min. On physical examination, the nurse finds that the umbilical cord is
protruding from the vagina. Which of the following actions should the nurse perform? Select all
that apply.
A) Placing the woman in knee-chest position
B) Administering oxygen at 2 to 4 L/min by nasal cannula
C) Administering terbutaline (Brethine) to stop contractions
D) With two gloved fingers, exerting upward pressure, into the vagina, on the presenting part
E) Wrapping the cord loosely in a sterile towel saturated with warm sterile normal saline
solution - ✔️✔️Answer: A, D, E
Rationale: When the umbilical cord is protruding, one of the first interventions the nurse should
perform is to relieve compression of the cord by exerting upward pressure on the presenting
part with two gloved fingers inserted vaginally. The cord must be protected from drying out and
from becoming compressed. Therefore it should be wrapped with towels soaked in warm,
sterile normal saline solution. The client is placed in an extreme Trendelenburg or modified
Sims position or knee-chest position to ease compression. Oxygen should be administered by
way of face mask at a rate of 8 to 10 L/min. A physician's prescription is needed for terbutaline,
but this medication is usually not given in these circumstances.
A nurse provides information to the mother of a child with diarrhea about signs and symptoms
that indicate the need to call the physician. Which statement by the mother indicates the need
for further instruction?
A) "I'll call the doctor if she gets dizzy and acts sick."
B) "I'll call the doctor if she has severe stomach cramps."
C) "I'll call the doctor if her temperature is 102° or higher."
D) "I'll call the physician if she goes longer than 6 hours without urinating." - ✔️✔️Answer: C
RN Examination Questions with 100% Correct
Answers
A client is receiving parenteral nutrition (PN) solution at 60 mL/hr by means of infusion pump
through a subclavian central line. The client calls the nurse and complains of difficulty breathing
and chest pain. The nurse notes that the client's pulse rate is increased, the blood pressure has
dropped, and oxygen saturation is 89%. Use the number 1 to denote the first action and the
number 4 the last.
~ Placing the client in lateral Trendelenburg position on the left side
~ Clamping the PN infusion catheter
~ Obtaining an electrocardiogram (ECG)
~ Notifying the physician - ✔️✔️The correct order is:
1) Clamping the PN infusion catheter
2) Placing the client in lateral Trendelenburg position on the left side
3) Notifying the physician
4) Obtaining an electrocardiogram (ECG)Rationale: One complication of subclavian central line
insertion is embolism, air or thrombus. Signs and symptoms include chest pain, dyspnea,
hypoxia, anxiety, tachycardia, and hypotension. On auscultation, the nurse would hear a loud
churning sound over the pericardium. If this sign is detected, the PN infusion catheter is
immediately clamped and the client placed in a lateral Trendelenburg position on the left side,
which helps trap the air in the apex of the ventricle and prevents its ejection into the
pulmonary arterial system. The physician would be notified. An ECG may be obtained, but this
would not be the immediate action.
A nurse is preparing to administer digoxin (Lanoxin) to a client with heart failure. On assessing
of the client, the nurse notes an apical pulse rate of 58 beats/min and the client complains of
anorexia and nausea. Which action should the nurse take first on the basis of these assessment
findings?
A) Contacting the physician
B) Administering an as-needed antiemetic
,C) Checking the most recent digoxin level
D) Administering the digoxin with an antacid - ✔️✔️Answer: C
Rationale: Anorexia and nausea are two of the symptoms most commonly associated with
digoxin toxicity. The nurse should withhold the digoxin until the physician has been consulted if
the pulse rate is slower than 60 beats/min, because bradycardia is also an indication of digoxin
toxicity. The nurse then checks the most recent digoxin level, which will provide additional data
to report to the physician — a key follow-up nursing action. The nurse would not administer an
antiemetic without further investigating the client's problem.
A nurse is assessing a client who has undergone radical neck dissection for the treatment of
cancer. The nurse hears this sound when auscultating over the trachea. On the basis of this
finding, the priority nursing action is to:
A) Contact the physician
B) Assess the client's pulse oximetry
C) Place the client in a supine position
D) Administer a nebulizer treatment with the use of a bronchodilator - ✔️✔️Answer: A
Rationale: The sound that the nurse hears is stridor. In the immediate postoperative period, the
nurse assesses the client for stridor, a high-pitched musical sound heard on inspiration during
auscultation over the trachea. This finding is reported immediately because it indicates airway
obstruction. The client is placed in the Fowler position to facilitate breathing and promote
comfort. Suctioning is performed to remove secretions that cannot be expectorated by the
client. Pulse oximetry may be performed, but this is not the priority of the options provided.
Administering a nebulizer treatment with a bronchodilator is not indicated at this time.
A nurse is caring for a hospitalized child with newly diagnosed type 1 diabetes mellitus who
received NPH and regular humulin insulin at 7:30 am. At 11 am the child suddenly complains of
dizziness, headache, and a shaky feeling. The nurse immediately:
A) Contacts the physician
B) Gives the child milk to drink
C) Arranges to have the child's lunch tray delivered early
D) Prepares to administer intravenous 5% dextrose solution - ✔️✔️Answer: B
,Rationale: Dizziness, headache, and a shaky feeling are signs of hypoglycemia. A blood glucose
reading will confirm the diagnosis and would be the initial action. However, because this is not
one of the options, the nurse would give the child milk to drink because of the child's history
and current symptoms indicating hypoglycemia. Other items used to treat hypoglycemia
include orange juice and hard candy. The nurse would prepare to administer intravenous 5%
dextrose solution if the child were not responsive enough to safely take oral fluids, but this is
not indicated in the question. Arranging to have the child's lunch tray delivered early is
inappropriate because the child should eat meals at basically the same time each day to
achieve the best control of the diabetes. Contacting the physician would not be the immediate
action.
A client with a diagnosis of preeclampsia suddenly begins to exhibit seizure activity. The first
action on the part of the nurse is:
A) Calling the physician
B) Inserting an oral airway
C) Turning the client on her side
D) Noting the time of the seizure - ✔️✔️Answer: C
Rationale: If seizure activity occurs, the nurse remains with the client and presses the
emergency bell for assistance. The client is turned on her side because a side-lying position
permits greater circulation through the placenta and helps prevent aspiration. The nurse then
notes the time and sequence of the seizure. The physician is notified that a seizure has
occurred, because this is an obstetric emergency associated with cerebral hemorrhage,
abruptio placentae, severe fetal hypoxia, and death. No object should be placed in the client's
mouth during a seizure. An airway may be inserted after the seizure, and the client's mouth and
nose are suctioned to prevent aspiration. Oxygen may be administered by way of face mask
during the seizure to increase oxygenation of the placenta and all maternal organs.
A nurse performs a bedside glucose test on a newborn infant whose mother has diabetes
mellitus and obtains a reading of 35 mg/dL. The nurse would first:
A) Ask the mother to breastfeed the newborn Incorrect
B) Bottle-feed the newborn with diluted glucose
C) Start an intravenous line for the administration of glucose
D) Ask the laboratory to perform a blood glucose test immediately - ✔️✔️Answer: D
, Rationale: The normal blood glucose level in a newborn is 40 mg/dL or higher. Glucose levels of
less than 40 to 45 mg/dL measured with bedside glucose screening should be reported and
verified in the laboratory. Although feeding is an intervention, the result of a bedside glucose
must be verified by the laboratory. Some infants need IV glucose to maintain glucose balance
and prevent damage to the brain.
A pregnant woman is being admitted to the maternity unit. The woman tells the nurse that she
felt a large gush of fluid from her vagina on the way to the hospital. The nurse detects a fetal
heart rate of 90 beats/min. On physical examination, the nurse finds that the umbilical cord is
protruding from the vagina. Which of the following actions should the nurse perform? Select all
that apply.
A) Placing the woman in knee-chest position
B) Administering oxygen at 2 to 4 L/min by nasal cannula
C) Administering terbutaline (Brethine) to stop contractions
D) With two gloved fingers, exerting upward pressure, into the vagina, on the presenting part
E) Wrapping the cord loosely in a sterile towel saturated with warm sterile normal saline
solution - ✔️✔️Answer: A, D, E
Rationale: When the umbilical cord is protruding, one of the first interventions the nurse should
perform is to relieve compression of the cord by exerting upward pressure on the presenting
part with two gloved fingers inserted vaginally. The cord must be protected from drying out and
from becoming compressed. Therefore it should be wrapped with towels soaked in warm,
sterile normal saline solution. The client is placed in an extreme Trendelenburg or modified
Sims position or knee-chest position to ease compression. Oxygen should be administered by
way of face mask at a rate of 8 to 10 L/min. A physician's prescription is needed for terbutaline,
but this medication is usually not given in these circumstances.
A nurse provides information to the mother of a child with diarrhea about signs and symptoms
that indicate the need to call the physician. Which statement by the mother indicates the need
for further instruction?
A) "I'll call the doctor if she gets dizzy and acts sick."
B) "I'll call the doctor if she has severe stomach cramps."
C) "I'll call the doctor if her temperature is 102° or higher."
D) "I'll call the physician if she goes longer than 6 hours without urinating." - ✔️✔️Answer: C
