HESI-SAUNDERS ONLINE REVIEW
FOR THE NCLEX-RN EXAMINATION
QUESTIONS & UPDATED DETAILED
ANSWERS
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 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).
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.
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 - 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.
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.
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
✔✔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 - 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.
A client with a basilar skull fracture has clear fluid leaking from the ears. The nurse should:
A) Assess the clear fluid for protein
B) Check the clear fluid for the presence of glucose
C) Place cotton balls or dry gauze loosely in the ears
D) Use an otoscope to assess the tympanic membrane for rupture - correct answer ✔✔Answer:
B
Rationale: Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar
skull fracture. CSF can be distinguished from other body fluids because it will separate into
bloody and yellow concentric rings on dressing material, a phenomenon referred to as the halo
sign. It also tests positive for glucose. CSF does not contain protein. The presence of CSF
indicates a disruption in the integrity of the cranium. Therefore inserting cotton balls, gauze, or
an otoscope into the ear puts the client at risk for infection.
A nurse is caring for a client who has just undergone cardioversion. Which of the following
interventions is the nurse's priority after this procedure?
A) Administering oxygen
B) Monitoring the blood pressure
C) Administering antidysrhythmic medications
D) Monitoring the client's level of consciousness - correct answer ✔✔Answer: A
Rationale: Nursing responsibilities after cardioversion include maintenance of a patent airway,
oxygen administration, assessment of vital signs and level of consciousness, and detection of
dysrhythmias. The priority nursing intervention here is administering oxygen.
FOR THE NCLEX-RN EXAMINATION
QUESTIONS & UPDATED DETAILED
ANSWERS
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 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).
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.
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 - 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.
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.
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
✔✔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 - 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.
A client with a basilar skull fracture has clear fluid leaking from the ears. The nurse should:
A) Assess the clear fluid for protein
B) Check the clear fluid for the presence of glucose
C) Place cotton balls or dry gauze loosely in the ears
D) Use an otoscope to assess the tympanic membrane for rupture - correct answer ✔✔Answer:
B
Rationale: Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar
skull fracture. CSF can be distinguished from other body fluids because it will separate into
bloody and yellow concentric rings on dressing material, a phenomenon referred to as the halo
sign. It also tests positive for glucose. CSF does not contain protein. The presence of CSF
indicates a disruption in the integrity of the cranium. Therefore inserting cotton balls, gauze, or
an otoscope into the ear puts the client at risk for infection.
A nurse is caring for a client who has just undergone cardioversion. Which of the following
interventions is the nurse's priority after this procedure?
A) Administering oxygen
B) Monitoring the blood pressure
C) Administering antidysrhythmic medications
D) Monitoring the client's level of consciousness - correct answer ✔✔Answer: A
Rationale: Nursing responsibilities after cardioversion include maintenance of a patent airway,
oxygen administration, assessment of vital signs and level of consciousness, and detection of
dysrhythmias. The priority nursing intervention here is administering oxygen.
