NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
The nurse is evaluating the client's potential for development of a pressure sore. Which of the following individual characteristics would be the best indicator of risk for the client's developing a pressure sore?
Correct Answer: C
Rationale: Immobility is the primary risk factor for pressure sores, as it leads to prolonged pressure on tissues.
Question 2 of 5
A client is ready to be discharged from same-day surgery following an inguinal hernia repair. Which criteria must the client meet before the nurse can discharge the client?
Correct Answer: C
Rationale: The ability to walk to the bathroom indicates sufficient recovery of mobility and stability, a key discharge criterion. Pain control and urination are also important, but mobility is critical.
Question 3 of 5
The client received electroconvulsive therapy (ECT) an hour ago and tells the nurse that he has a headache. Which response by the nurse is best?
Correct Answer: B
Rationale: Offering acetaminophen addresses the client's complaint directly and safely, as headaches are a common side effect of ECT. Informing the client that headaches are common does not provide relief, and a nap or unclear commands are not appropriate responses.
Question 4 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 5 of 5
A client has been scheduled for a barium swallow (esophagography). The nurse determines that the client understands preprocedure instructions when the client states the intention to take which action before the test?
Correct Answer: D
Rationale: A barium swallow, or esophagography, is a radiograph that uses a substance called barium for contrast to highlight abnormalities in the gastrointestinal (GI) tract. The client is told to remove metal objects such as medals and jewelry before the test so that they will not interfere with radiographic visualization of the field. Some oral medications are withheld before the test, and the client should follow the primary health care provider's instructions regarding medication administration. The client should fast for a minimum of 8 hours before the test, depending on primary health care provider's instructions. It is important after the procedure to monitor for constipation, which can occur as a result of the presence of barium in the GI tract.