Saunders NCLEX RN review EXAM A+ GRADE ASSURED COMPLETE SOLUTIONS AND VERIFIED ANSWERS LATEST UPDATE!!!!

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HESI/Saunders Online Review for the NCLEX RN Exami zm zm zm zm zm zm zm




nation (1 Year) 2026 A+ GRADE ASSURED COMPLETE S
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OLUTIONS AND VERIFIED ANSWERS (BA1AD) zm zm zm zm




QUESTION 1 zm




A nurse is caring for client with increased intracranial pressure (ICP). In which positi
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on should the nurse maintain the client?
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A) Supine, with the head extended
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B) Side-lying, with the neck flexed
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C) Supine, with the head turned to the side
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D) Head midline and elevated 30 to 45 degrees
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ANSWER

Answer: D Rationale: The client with increased ICP should be positioned with the head in a neutral
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midline position. It is the responsibility of the nurse to ensure that all those delivering care to the c
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lient maintain the proper positioning. The client should avoid flexing or extending the neck or turni
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ng the neck side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper p
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ositioning promotes venous drainage from the cranium to keep ICP down.
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QUESTION 2 zm




A client with a basilar skull fracture has clear fluid leaking from the ears. The nurse s
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hould:
A) Assess the clear fluid for protein
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B) Check the clear fluid for the presence of glucose
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C) Place cotton balls or dry gauze loosely in the ears
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D) Use an otoscope to assess the tympanic membrane for rupture
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ANSWER

Answer: B Rationale: Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany bas
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ilar skull fracture. CSF can be distinguished from other body fluids because it will separate into bloo
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dy and yellow concentric rings on dressing material, a phenomenon referred to as the halo sign. It a
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lso tests positive for glucose. CSF does not contain protein. The presence of CSF indicates a disrupti
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on in the integrity of the cranium. Therefore inserting cotton balls, gauze, or an otoscope into the ea
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r puts the client at risk for infection.
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, QUESTION 3 zm




A nurse is caring for a client who has just undergone cardioversion. Which of the follo
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wing interventions is the nurse's priority after this procedure?
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A) Administering oxygen
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B) Monitoring the blood pressure
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C) Administering antidysrhythmic medications
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D) Monitoring the client's level of consciousness
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ANSWER

Answer: A Rationale: Nursing responsibilities after cardioversion include maintenance of a patent air
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way, oxygen administration, assessment of vital signs and level of consciousness, and detection of dy
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srhythmias. The priority nursing intervention here is administering oxygen.
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QUESTION 4 zm




A nurse caring for a client with AIDS is monitoring the client for signs of complication
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s. Which of the following findings would cause the nurse to suspect infection with Pne
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umocystis jiroveci? Select all that apply. zm zm zm zm zm



A) Diarrhea
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B) Tachypnea
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C) Pedal edema
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D) Intermittent fever
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E) Dyspnea when ambulating F) Expectoration of frothy mucus
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ANSWER

Answer(s): B, D, E Rationale: Pneumocystis jiroveci pneumonia is a very common and severe opport
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unistic infection affecting the client with AIDS. Clinical manifestations include dyspnea, nonproductiv
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e cough, intermittent fever, fatigue, anorexia, weight loss, and tachypnea. Persons with advanced dise
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ase may exhibit crackles, decreased breath sounds, and cyanosis. Diarrhea and pedal edema are not
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associated with this infection. zm zm zm




QUESTION 5 zm




Zidovudine (AZT, Retrovir) is prescribed for a client with AIDS. The nurse tells the cli
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ent that it is important to report back to the clinic as scheduled for follow-up:
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A) Blood glucose checks
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B) Blood pressure checks
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C) Complete blood counts (CBCs)
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D) Electrocardiographic (ECG) studies
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ANSWER

Answer: C Rationale: Zidovudine is an antiviral medication. Common side effects include agranulocyt
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openia and anemia. The nurse carefully monitors CBC results for these changes. With early infection
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or in the client who is asymptomatic, a CBC is usually performed monthly for 3 months, then every
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