TEST BANK
FULL TESTBANK | RATED GRADE A|MULTICHOICES | DETAILED
RATIONALES|LATEST UPDATE| GUARANTEED PASS| 100% PASS
HESI/Saunders Review, HESI/Saunders Online Review-
Module 10-Physiological Health Problems Exam
,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(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(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 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)
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 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: 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: 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.
FULL TESTBANK | RATED GRADE A|MULTICHOICES | DETAILED
RATIONALES|LATEST UPDATE| GUARANTEED PASS| 100% PASS
HESI/Saunders Review, HESI/Saunders Online Review-
Module 10-Physiological Health Problems Exam
,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(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(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 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)
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 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: 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: 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.
