HESI/SAUNDERS TEST REVIEWHESI/SAUNDERS TEST REVIEWHESI/SAUNDERS TEST REVIEWHESI/SAUNDERS TEST REVIEWHESI/SAUNDERS TEST REVIEWHESI/SAUNDERS TEST REVIEWHESI/SAUNDERS TEST REVIEWHESI/SAUNDERS TEST REVIEWHESI/SAUNDERS TEST REVIEWHESI/SAUNDERS TEST REVIEWHESI/SAUNDERS TEST REVIEWHESI/SAUNDERS...
HESI/SAUNDERS TEST REVIEW
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 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 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.
A client with diabetes mellitus who is scheduled to have blood drawn for determination
of the glycosylated hemoglobin (HbA1C) level asks the nurse why the test is necessary
if he is performing blood glucose monitoring at home. The nurse tells the client that this
test is used specifically to:
A) Detect diabetic complications
B) Assess long-term glycemic control
C) Determine whether the client is at risk for hypoglycemia
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller MARIESTOPES1. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $7.29. You're not tied to anything after your purchase.
