HESI/Saunders Online Review for the NCLEX-RN
Examination 75 questions and answer with rationales
2025\2026 update (passing score 100% guaranteed)
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 (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.
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.
A) Normal deep tendon reflexes
B) Improved skeletal muscle tone
, E) Po2 of 85% and Pco2 of 40 mm Hg:
CORRECT ANSWER (s): D,E
Rationale: Satisfactory respiratory outcomes include clear breath sounds o
auscultation, clear mentation, spontaneous breathing, normal vital capacity, an
normal arterial blood gases. The ABG results listed here — a Po2 of 85% and a Pco
of 40 mm Hg — are normal. The presence of normal deep tendon reflexes, improve
skeletal muscle tone, and absence of paresthesias in the lower extremities refle
improvement in the symptoms associated with Guillain-Barré but are not specific
a respiratory outcome.
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 :
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 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 ma
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).
4. A nurse developing a plan of care for a client with a spinal cord injury include
measures to prevent autonomic dysreflexia (hyperreflexia). Which of the
following interventions does the nurse incorporate into the plan to prevent th
complication?
A) Keeping a fan running in the client's room
B) Keeping the linens wrinkle-free under the client
, D) Avoiding the administration of enemas and rectal suppositories:
CORRECT ANSWER : B
Rationale: The most frequent causes of autonomic dysreflexia are a distended bladd
and impacted feces in the rectum. Straight catheterization should be performed eve
4 to 6 hours, and the Foley catheter should be checked frequently to prevent kinks
the tubing. Constipation and fecal impaction are other causes, so maintaining bow
regularity is important. Other causes include stimulation of the skin by tactil
thermal, or painful stimuli. The nurse renders care in such a way as to minimize ri
in these areas.
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."
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 : C
Rationale: The client should cleanse the skin under the lambs-wool liner each day
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 smal
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.
6. A nurse is caring for client with increased intracranial pressure (ICP). In whic
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 : 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 tho
delivering care to the client maintain the proper positioning. The client should avo
flexing or extending the neck or turning the neck side to side. The head of the be
Examination 75 questions and answer with rationales
2025\2026 update (passing score 100% guaranteed)
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 (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.
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.
A) Normal deep tendon reflexes
B) Improved skeletal muscle tone
, E) Po2 of 85% and Pco2 of 40 mm Hg:
CORRECT ANSWER (s): D,E
Rationale: Satisfactory respiratory outcomes include clear breath sounds o
auscultation, clear mentation, spontaneous breathing, normal vital capacity, an
normal arterial blood gases. The ABG results listed here — a Po2 of 85% and a Pco
of 40 mm Hg — are normal. The presence of normal deep tendon reflexes, improve
skeletal muscle tone, and absence of paresthesias in the lower extremities refle
improvement in the symptoms associated with Guillain-Barré but are not specific
a respiratory outcome.
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 :
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 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 ma
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).
4. A nurse developing a plan of care for a client with a spinal cord injury include
measures to prevent autonomic dysreflexia (hyperreflexia). Which of the
following interventions does the nurse incorporate into the plan to prevent th
complication?
A) Keeping a fan running in the client's room
B) Keeping the linens wrinkle-free under the client
, D) Avoiding the administration of enemas and rectal suppositories:
CORRECT ANSWER : B
Rationale: The most frequent causes of autonomic dysreflexia are a distended bladd
and impacted feces in the rectum. Straight catheterization should be performed eve
4 to 6 hours, and the Foley catheter should be checked frequently to prevent kinks
the tubing. Constipation and fecal impaction are other causes, so maintaining bow
regularity is important. Other causes include stimulation of the skin by tactil
thermal, or painful stimuli. The nurse renders care in such a way as to minimize ri
in these areas.
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."
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 : C
Rationale: The client should cleanse the skin under the lambs-wool liner each day
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 smal
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.
6. A nurse is caring for client with increased intracranial pressure (ICP). In whic
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 : 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 tho
delivering care to the client maintain the proper positioning. The client should avo
flexing or extending the neck or turning the neck side to side. The head of the be
