NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
The nurse makes a home visit to a primiparous client and her neonate at 1 week after a vaginal delivery. Which of the following findings should be reported to the physician?
Correct Answer: D
Rationale: Neonatal central cyanosis indicates possible respiratory or cardiac issues and requires immediate reporting. The other findings are normal at 1 week postpartum.
Question 2 of 5
A client is prescribed diphenhydramine 1% as a topical agent for allergic dermatosis. The nurse evaluates that the medication is having the intended effect when the client reports relief of what complaint?
Correct Answer: B
Rationale: Diphenhydramine is an antihistamine medication that has many uses. When used as a topical agent on the skin, it reduces the symptoms of allergic reaction, such as itching or urticaria. It does not act to relieve pain, headache, or skin redness.
Question 3 of 5
A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, the nurse should first?
Correct Answer: A
Rationale: Meningococcal meningitis is transmitted via droplets, so instituting precautions is the priority to prevent spread.
Question 4 of 5
To prevent development of peripheral neuropathies associated with isoniazid administration, the nurse should teach the client to:
Correct Answer: D
Rationale: Isoniazid can deplete vitamin B6, leading to neuropathy; supplementation prevents this side effect.
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.