NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
The nurse assists the physician in inserting a temporary pacemaker into the client. After the procedure, the nurse should verify that which of the following has been documented?
Correct Answer: D
Rationale: Documenting the pacemaker rate, type, and settings is critical to ensure proper function and patient safety post-procedure. While cardiovascular status and sedation are important, the pacemaker specifics are the priority for verification.
Question 2 of 5
The nurse is assigned to care for a client with a chest tube attached to closed chest drainage. Which assessment data should the nurse identify as an indicator that the client's lung has completely expanded?
Correct Answer: C
Rationale: When the lung has completely expanded, there is no longer air in the pleural space causing fluctuations in the water-seal chamber. Thus, an indication that a chest tube is ready for removal is when fluctuations in the water-seal chamber cease. Although air is known to be an irritant to pleural tissue, cessation of pleuritic pain does not indicate that the lung is expanded. The chest tube acts as an irritant and therefore contributes to pain. Adequate oxygen saturation does not imply that the lung has fully reexpanded. Use or nonuse of suction in the chest drainage system is not necessarily governed by the degree of lung expansion. Suction is indicated when gravity is not sufficient to drain air and pleural fluid or if the client has a poor respiratory effort and cough.
Question 3 of 5
A client is admitted to the hospital after sustaining a fall from a roof. The client has multiple lacerations and a right leg fracture, which has been treated with a plaster cast. How should the nurse position the client's leg to promote optimal circulation?
Correct Answer: D
Rationale: A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and promote venous drainage. The other options are not part of standard positioning of the newly casted extremity.
Question 4 of 5
The physician orders I.V. cefazolin (Kefzol) 1g for a client. In preparing to administer the Kefzol, the nurse notes that the client is allergic to penicillin. Based on this information, what is an appropriate action for the nurse to take?
Correct Answer: B
Rationale: Cefazolin, a cephalosporin, has a risk of cross-reactivity in penicillin-allergic clients, so the nurse should notify the physician to consider an alternative. Administering or verifying with the pharmacist without physician consultation is unsafe.
Question 5 of 5
A client with a hip fracture is scheduled for surgery. Which preoperative teaching should the nurse include?
Correct Answer: C
Rationale: Incentive spirometry prevents postoperative pulmonary complications like atelectasis, critical for a client with limited mobility post-hip surgery.