NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 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.
Question 2 of 5
Sertraline is prescribed for a client in the treatment of depression. Before administering the medication, the nurse reviews the client's record and consults with the primary health care provider when which finding is noted?
Correct Answer: A
Rationale: Sertraline is a serotonin reuptake inhibitor. Serious potentially fatal reactions may occur if sertraline is administered concurrently with a monoamine oxidase inhibitor (MAOI). Phenelzine sulfate is an MAOI. MAOIs should be stopped at least 14 days before sertraline therapy. Sertraline should also be stopped at least 14 days before MAOI therapy. The remaining options are not concerns associated with the administration of this medication.
Question 3 of 5
A Hispanic client is admitted to the surgical unit from the emergency department for an appendectomy. The nurse conducts the preoperative preparations and determines that the client has difficulty understanding English. The surgeon needs to obtain the client's informed consent. The nurse course for obtaining the client's informed consent is to:
Correct Answer: C
Rationale: The surgeon is required to give the client explanations and have questions answered. The nurse has no way of assessing the client's understanding without the interpreter. The client should sign the Spanish consent form only after receiving an explanation of the procedure, its risks, and alternatives. A family member cannot be relied on to translate the surgeon's instructions accurately.
Question 4 of 5
A client with a history of chronic obstructive pulmonary disease (COPD) is prescribed tiotropium (Spiriva). The nurse should instruct the client to:
Correct Answer: B
Rationale: Rinsing the mouth after tiotropium inhalation prevents oral thrush.
Question 5 of 5
The nurse is assessing the leg pain of a client who has just undergone right femoral-popliteal artery bypass grafting. Which question would be most useful in determining whether the client is experiencing graft occlusion?
Correct Answer: D
Rationale: The most frequent indication that a graft is occluding is the return of pain that is similar to that experienced preoperatively. Standard pain assessment techniques also include the items described in the remaining options, but these will not help differentiate current pain from preoperative pain.