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
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 3 of 5
A client with a history of seizures is prescribed phenytoin (Dilantin). The nurse should instruct the client to report which of the following side effects immediately?
Correct Answer: C
Rationale: A rash may indicate a serious hypersensitivity reaction to phenytoin, such as Stevens-Johnson syndrome, requiring immediate reporting.
Question 4 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 5 of 5
Which of these skills is most closely related to successfully meeting the established priority needs of a group of clients?
Correct Answer: A
Rationale: Time management skills are critical for prioritizing and addressing the needs of multiple clients efficiently, ensuring that high-priority tasks are completed in a timely manner.