NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
A client with type 2 diabetes is admitted with a blood glucose level of 450 mg/dL. The nurse should anticipate which of the following orders?
Correct Answer: A
Rationale: Hyperglycemia requires regular insulin IV to rapidly lower blood glucose. Metformin is oral and slower, glucagon raises glucose, and potassium is not indicated without further assessment.
Question 2 of 5
When a client states that he is allergic to amoxicillin (Ampicillin) even though his medication administration record and armband do not indicate medication allergies, the nurse should:
Correct Answer: B
Rationale: Withholding the medication is the safest action until the allergy can be verified to prevent an allergic reaction.
Question 3 of 5
A client with a history of type 2 diabetes is prescribed exenatide (Byetta). The nurse should instruct the client to:
Correct Answer: A, B
Rationale: Exenatide is taken before meals to control postprandial glucose, and hypoglycemia is a risk.
Question 4 of 5
A 4-year-old child is admitted with dehydration due to gastroenteritis. Which assessment finding indicates severe dehydration?
Correct Answer: C
Rationale: Sunken fontanelles in a young child are a sign of severe dehydration, indicating significant fluid loss requiring urgent rehydration.
Question 5 of 5
Which actions should the nurse implement to prevent ventilator-associated pneumonia (VAP) in the client who is intubated and on mechanical ventilation?
Correct Answer: A
Rationale: Because normal upper airway defenses are bypassed, clients who are intubated with mechanical ventilation are at risk for VAP. Prevention includes effective hand washing before and after suctioning, when touching ventilator equipment, and when in contact with respiratory secretions.
To prevent aspiration of colonized secretions from the oral cavity, the client will need more frequent oral cavity suctioning and at least 30 degrees head of the bed elevation. The more frequently the circuit is broken, the greater the risk for pathogen entry.