HESI/Saunders Online Review for the NCLEX-RN Examination (1 Year)

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Teacher Fra 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.

• Assessing the radial pulse in the right extremity
• Using the left arm to take blood pressure readings
• Drawing predialysis blood specimens from the left

arm D) Assessing the area over the AV fistula for a bruit and thrill each shift

• Placing a pressure dressing over the site after each

dialysis treatment

• 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.

• Normal deep tendon reflexes
• Improved skeletal muscle tone
• Absence of paresthesias in the lower extremities
• Clear sounds in the lower lung fields bilaterally
• 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)

• Calling the rapid response team
• Preparing the client for cardioversion
• Asking the client to bear down and cough
• 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?

• Keeping a fan running in the client's room
• Keeping the linens wrinkle-free under the client
• Limiting bladder catheterization to once every 12

hours

• 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?

• "I need to get more fluids and fiber into my diet."
• "I should cut my food into small pieces before I eat."
• "I need to put powder under the vest twice a day to

prevent sweating."

• "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?

• Supine, with the head extended
• Side-lying, with the neck flexed
• Supine, with the head turned to the side
• 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:

• Assess the clear fluid for protein
• Check the clear fluid for the presence of glucose
• Place cotton balls or dry gauze loosely in the ears
• 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?

• Administering oxygen
• Monitoring the blood pressure
• Administering antidysrhythmic medications
• 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:

• Detect diabetic complications
• Assess long-term glycemic control
• Determine whether the client is at risk for

hypoglycemia

• Determine whether the prescribed insulin dosage is

adequate

Answer: B

Rationale: The HbA1C reading provides an indication of glycemic control over the preceding 3 months. An HbA1C value of less than 7% indicates good glycemic control. When increases in the blood glucose occur, some glucose molecules attach themselves to red blood cells (RBCs) and remain there for the life of the RBCs. Therefore a high value on this test is correlated with a high blood glucose level, indicating poor long-term control of blood glucose, which often leads to the development of complications in the client with diabetes mellitus. The other options are not purposes for this test.A nurse caring for a client with AIDS is monitoring the client for signs of complications. Which of the following findings would cause the nurse to suspect infection with Pneumocystis jiroveci? Select all that apply.

• Diarrhea
• Tachypnea
• Pedal edema
• Intermittent fever
• Dyspnea when ambulating
• Expectoration of frothy mucus

Answer(s): B, D, E

Rationale: Pneumocystis jiroveci pneumonia is a very common and severe

opportunistic infection affecting the client with AIDS. Clinical manifestations include dyspnea, nonproductive cough, intermittent fever, fatigue, anorexia, weight loss, and tachypnea. Persons with advanced disease may exhibit crackles, decreased breath sounds, and cyanosis. Diarrhea and pedal edema are not associated with this infection.Zidovudine (AZT, Retrovir) is prescribed for a client with AIDS. The nurse tells the client that it is important to

report back to the clinic as scheduled for follow-up:

• Blood glucose checks
• Blood pressure checks
• Complete blood counts (CBCs)
• Electrocardiographic (ECG) studies

Answer: C

Rationale: Zidovudine is an antiviral medication. Common side effects include

agranulocytopenia and anemia. The nurse carefully monitors CBC results for these changes. With early infection or in the client who is asymptomatic, a CBC is usually performed monthly for 3 months, then every 3 months thereafter. In clients with advanced disease, a CBC is usually performed every 2 weeks for the first 2 months and then once a month if the medication is tolerated well. This medication does not affect the blood glucose level, blood pressure, or cardiac status.After a nonimmunocompromised client undergoes a Mantoux test for tuberculosis (TB) infection, an area of induration 6 mm wide develops. The client asks the nurse

what this result means. The nurse's best response is:

• "We'll have to repeat the test, because the result is

inconclusive."

• "The swollen area is small, so that means your test

result is negative."

• "You've been exposed to tuberculosis, so you'll need

to have a chest x-ray."

• "You need to get started on medication right away,

because you've got tuberculosis."

Answer: B

Rationale: An area of induration of less than 10 mm is considered a negative result.An area of induration (not redness) measuring 10 mm or more in diameter 48 to 72 hours after injection in a client without immunosuppressive disease indicates exposure to and possible infection with TB. A reaction of 5 mm or greater is considered positive in immunocompromised individuals. A positive reaction does not mean that active disease is present but instead indicates exposure to TB or the presence of inactive (dormant) TB. Further testing, including a chest x-ray and sputum culture, would be required if the reaction were positive.

A client's arterial blood gases (ABGs) are analyzed: pH

7.49, Paco2 31 mm Hg, Pao2 97 mm Hg, HCO3- 22 mEq/L.Which of the following acid-base disturbances does the nurse identify from these results?

• Metabolic acidosis
• Metabolic alkalosis
• Respiratory acidosis
• Respiratory alkalosis

Answer: D

Rationale: Acidosis is defined as a pH of less than 7.35, whereas alkalosis is

defined as a pH greater than 7.45. Respiratory acidosis is present when the Paco2 is greater than 45 mm Hg; respiratory alkalosis is present when the Paco2 is less than 35 mm Hg. Metabolic acidosis is present when the HCO3- is less than 22 mEq/L; metabolic alkalosis is present when the HCO3- is greater than 26 mEq/L.This client's ABG results are consistent with respiratory alkalosis.A client has just been found to have deep vein thrombosis (DVT) of the right leg. Which of the following interventions does the nurse immediately implement?

• Elevating the foot of the bed 6 inches
• Placing ice packs on and under the right leg
• Documenting the need for hourly calf measurements
• Performing passive range-of-motion exercises of the

right leg

Answer: A

Rationale: Standard therapy for DVT consists of bed rest, leg elevation, and

application of warm, moist heat to the affected leg. Elevation of the legs decreases venous pressure, which in turn relieves edema and pain. The client may have calf measurements prescribed once per shift or once per day, but they would not be obtained hourly. Placing ice packs on and under the right leg is incorrect, because heat, not cold, is usually prescribed. Passive range-of-motion exercises of the right leg would be dangerous to the client because activity after clot formation can cause pulmonary embolus.A nurse provides instruction to a client with chronic obstructive pulmonary disease (COPD) about home oxygen therapy. Which statement by the client indicates a need for further instruction? Select all that apply.

• "I should limit activity as much as I possibly can."
• "If I have trouble breathing, I need to call the doctor."
• "I need to drink lots of fluids to keep my mucus thin."
• "I can apply Vaseline to my nose if the oxygen dries it

out."

• "I should wear a scarf over my nose and mouth in cold

weather."

• "If I get a flu shot, I don't have to worry about being

around people with colds."

Answer(s): A, D, F

Rationale: Clients with COPD should be encouraged to keep up their daily

activities as much as possible to help prevent muscle wasting and maintain activity tolerance. An occupational therapy consult may be useful in helping the client learn how to perform activities in ways that conserve energy. Oxygen is drying to the membranes of the nose, but the client should apply a water-soluble lubricant (K-Y Jelly) to the inside of the nose to reduce dryness and cracking rather than petroleum jelly (Vaseline), which could be inhaled. Every client with COPD should be encouraged to get a yearly flu vaccination, but because of the increased risk of infection, the client must still avoid crowds and people with infections. The remaining options are appropriate home care measures.A nurse is monitoring the neurological status of a client who underwent craniotomy 3 days ago. Which of the following signs or symptoms would prompt the nurse to notify the surgeon immediately?

• Disorientation to date
• Pupils equal and reactive at 4 mm
• Mild headache relieved by codeine sulfate Incorrect
• Pain with forward flexion of the neck onto the chest

Answer: D

Rationale: One of the complications of cranial surgery is meningitis. Signs of

meningeal irritation include nuchal rigidity, which is characterized by a stiff neck and soreness and is especially noticeable when the neck is flexed. Pupils that are equal and reactive at 4 mm are normal. Mild headache relieved by codeine sulfate is an expected finding at this point after craniotomy. Disorientation to date is not the matter of greatest concern when the client has been hospitalized for cranial surgery.A man calls the emergency department and tells the nurse that he sustained a bee sting on his leg while working in his yard. The client states that he is not allergic to bees and wants to know how to treat the sting. The

nurse tells the client to first:

• Place a cool compress on the sting site
• Apply an antipruritic lotion to the sting site
• Apply a topical corticosteroid to the sting site
• Take an oral antihistamine such as diphenhydramine

(Benadryl)

Answer: A

Rationale: Treatment for a bee sting depends on the severity of the reaction. Mild reactions are treated with elevation, cool compresses, antipruritic lotions, and oral antihistamines. Rings, watches, and restrictive clothing are removed. In this situation, there is no information to indicate that the client is experiencing a severe reaction, so the nurse would first tell the client to apply a cool compress to the sting site. More severe reactions are treated with intravenous antihistamines such as diphenhydramine, subcutaneous epinephrine, and corticosteroids.