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HESI/Saunders Online Review for the NCLEX-RN Examination questions with correct answers
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HESI/Saunders Online Review for the NCLEX-RN Examination questions with correct answers
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HESI/Saunders Online Review for theNCLEX-RN Examination questions with
correct answers
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.
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 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 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 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
D) |Determine |whether |the |prescribed |insulin |dosage |is |adequate Answer: |B
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