Saunders Comprehensive NCLEX-RN review with 100% correct solutions needed to pass

HESI Saunders Online Review For The NCLEX-RN Examination (1
b n n n n n n n




Year) With Correct Solution A+ Already Passed.
bn n n n n n n




1. Anurseisassignedtocareforaclientwithchronicrenalfailurewhoisundergoing n b




b hemodialysis through an internal arteriovenous (AV) fistula in therightarm.
b b b b b b b b b




Whichofthefollowinginterventionsshouldthenurseimplementin caringforthe
b b




b client?Selectallthatapply. n




A) Assessing the radial pulse in the right extremity b b b b b b b




B) Using the left arm to take blood pressure readings
b b b b b b b b




C) DrawingpredialysisbloodspecimensfromtheleftarmD)Assessingthearea over
b b b b b b b b b b b




the AVfistula forabruitand thrilleachshift
b b b b




E) Placingapressuredressingoverthesiteaftereachdialysistreatment
F) Administeringintravenous(IV)fluidsthroughthevenoussiteoftheAVfistula as b b




b needed:Answer(s):ANSA,B,C,D n n




Rationale:SeveralprecautionsmustbeobservedtoensurethefunctionofaninternalAVfistula.Thenurseassesses thefistula,
b b b b b b b b b b b b b b b n




andthedistalportionoftheextremity,foradequatecirculation;checksforabruitandathrillbymeansofauscultationorpalpation
b n b b




b overtheaccesssite;monitorstheradialpulseintheextremity;andavoidstakingblood
pressurereadingsordrawingbloodfrom thearmwiththeAVfistula. VenipunctureisavoidedintheextremitybearingtheAVfistula. b b




BloodisneverdrawnfromtheAVfistula,andtheAVfistulaisnotusedfortheadministrationofIVfluids.TheAVfistulasiteisnotcovered
b n n




withapressuredressingafterdialysis.
b n n




2. Anurseisevaluatingoutcomesf ora clientwithGuillain-Barrésyndrome.
b b b b b b b




Whichofthefollowingoutcomes doesthenurse recognize asoptimal respi-
b b b b b




ratoryoutcomesfortheclient?Selectallthatapply.
b b b b b




A) Normal deep tendon reflexes b b b




B) Improved skeletal muscle tone b b b




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b

,C) Absence of paresthesias in the lower extremities
b b b b b b




D) Clear sounds in the lower lung fields bilaterally
b b b b b b b




E) Po2of85%andPco2of40mmHg:Answer(s):ANSD,E
Rationale:Satisfactoryrespiratoryoutcomesincludeclearbreathsoundsonauscultation,clearmentation,spontaneous b




b breathing,normalvitalcapacity,andnormalarterialbloodgases.TheABGresultslistedhere—aPo2of85%andaPco2of b b




b 40mmHg—arenormal.Thepresenceofnormaldeeptendonreflexes,improvedskeletalmuscletone,andabsenceof b




paresthesiasinthelowerextremitiesreflectimprovementinthesymptomsassociatedwithGuillain-Barrébut arenotspecific to
b b b b b b b b b b b b b n n




arespiratoryoutcome.
b




3. Anurseonthetelemetry u nitiscaringfora clientw hohashadamyocardial
b b b b




binfarction andisnowattachedtoacardiac monitor. Thenurse, monitoring the
b b b b b




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,client's cardiac rhythm, notes the rhythm depicted in the image. Which of the
b b b b b b b b b b b b




followingnursingactionsshouldthenursetake?
b




(Rhythm iscontinuous upanddown inpic)
b b b b b b b




A) Calling the rapid response team b b b b




B) Preparingtheclientforcardioversion
C) Asking the client to bear down and cough b b b b b b b




D) Preparingtoadministerdiltiazem(Cardiazem):ANSAnswer:A b




Rationale:Thispatternindicatesventricularfibrillation(VF).Clientswhohavesustainedamyocardialinfarctionareat greatrisk
b b b b b b b b b b b b b b n




forVF.WiththeonsetofVFtheclientfeelsfaint,thenimmediatelylosesconsciousnessandbecomespulseless andapneic.There
b b




b isnobloodpressure,andheartsoundsareabsent.ThegoalsoftreatmentaretoterminateVFpromptly and convert it to an b b b b b




b organized rhythm. Because defibrillation is theimmediate treatment, the nurse mustcalltherapidresponseteamandinitiate
b b b b b b b b b b




cardiopulmonaryresuscitation.Theclientwouldnotbeable tobeardown orcough.Cardioversionisasynchronized
b b b




b countershockthatmaybeperformedinemergenciesforunstableventricularorsupraventriculartachydysrhythmiasor b b b




b electivelyforstabletachydysrhythmiasthatareresistanttomedicaltherapiessuchastheadministrationofdiltiazem b b




b (Cardiazem).
4. Anursedevelopingaplanofcareforaclientwithaspinalcordinjuryincludes
n




measurestopreventautonomic dysreflexia (hyperreflexia). Whichofthefol-
b b b b b b b




lowinginterventionsdoesthenurseincorporate i ntotheplantoprevent this
b b b b




complication?
b




A) Keeping a fan running in the client's room b b b b b b b




B) Keeping the linens wrinkle-free under the client b b b b b b




C) Limiting bladder catheterization to once every 12 hours b b b b b b b




D) Avoiding the administration of enemas and rectal suppositories:ANS Answer:B
b b b b b b b b b b b b b b b b b




b Rationale:Themostfrequentcausesofautonomicdysreflexiaareadistendedbladderandimpactedfecesintherectum.Straight b




b catheterizationshouldbeperformedevery4to6hours,andtheFoleycathetershouldbecheckedfrequentlytopreventkinksin
b b b b b b b b b b b b b b b b n




thetubing.Constipationandfecalimpactionareothercauses,somaintainingbowelregularityisimportant.Othercauses
b n




includestimulationoftheskinbytactile,thermal,orpainfulstimuli.Thenurserenderscareinsuchawayastominimizeriskin
b b b




b theseareas.
5. A nurse provideshome care instructions toaclientwho has been fitted with a halo device
b b b b b b b b b b b b b b b b




to treat a cervical fracture. Which statement by the client indicates the need
b b b b b b b b b b b b b




forfurtherinstruction?
b




A) "Ineedtogetmorefluidsandfiberintomydiet."
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, B) "I should cut my food into small pieces before I eat."
b b b b b b b b b b




C) "Ineedtoputpowderunderthevesttwiceadaytopreventsweating." n n




D) "Ihavetocheckthepinsiteseverydayandwatchforsignsofinfection.":ANS An-
b b b b b b b b b b b b




swer:C b




Rationale:Theclientshouldcleansetheskinunderthelambs-woollinereachdaytopreventrashesorsores.Powderorlotionsshould
n n b




bbeusedonlysparinglyornotatall becausetheymaycake,resultinginskinirritation.Theclientshouldincreaseintakeoffluidand n n b b




bfibertohelppreventconstipation.Foodshouldbecut intosmall piecestofacilitatechewing andswallowing.Theclientshould n n b b




balsouseastrawfordrinking.Thepinsitesshouldbecheckeddailyforsignsofinfection.
6. A nurse is caring for client with increased intracranial pressure (ICP). In which
b b b b b b b b b b b b




position shouldthenursemaintaintheclient?
b b b




A) Supine,withtheheadextended b b b




B) Side-lying, with the neck flexed b b b b




C) Supine, with the head turned to the side b b b b b b b




D) Headmidlineandelevated30to45degrees:Answer:D n b b b




b Rationale:TheclientwithincreasedICPshouldbepositionedwiththeheadinaneutralmidlineposition.Itisthe
n




b responsibilityofthenursetoensurethatallthosedeliveringcaretotheclientmaintaintheproperpositioning.Theclient n n n




bshouldavoidflexingorextendingtheneckorturningthenecksidetoside.Theheadofthebedshouldberaisedto30to45 n n n n n n




degrees.UseofproperpositioningpromotesvenousdrainagefromthecraniumtokeepICPdown.
b




7. Aclientwithabasilarskull fracturehasclearfluidleakingfrom the ears.Thenurse
b b b b b b b b b b b b b




should:
b




A) Assess the clear fluid for protein b b b b b




B) Checkthe clearfluidforthepresence ofglucose b b b b




C) Placecottonballsordry gauzelooselyintheears
b b b




D) Use an otoscope to assess the tympanic membrane for rupture: Answer: B
b b Rationale: Leakage
b b b b b b b n b b b b b




ofcerebrospinalfluid(CSF)fromtheearsornosemayaccompanybasilarskullfracture.CSFcanbedistinguishedfrom
b b b b b b b b b b b b b b b b




otherbodyfluidsbecauseitwillseparateintobloodyandyellowconcentricringsondressingmaterial,aphenomenon
b n n b




referredtoasthehalosign.Italsotestspositiveforglucose.CSFdoesnotcontainprotein.ThepresenceofCSFindicatesa
b b b b b b b b b b




disruptionintheintegrityofthecranium.Thereforeinsertingcottonballs,gauze,oranotoscopeintotheearputstheclientat
b n n b b b




b riskforinfection.
8. A nurse iscaring fora client whohasjustundergone cardioversion. Whichofthe
n b b b b b b




following interventions is the nurse's priority after this procedure?
b b b b b b b b b




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