NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
Your client has a doctor's order for the antihistamine medication diphenhydramine for sleep. What should you do?
Correct Answer: D
Rationale: Diphenhydramine (Benadryl) is commonly used off-label for sleep due to its sedative effects, making it an appropriate choice if ordered for this purpose.
Question 2 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 3 of 5
The nurse is caring for a client who has just undergone a total hip replacement. Which of the following positions should the nurse avoid placing the client in?
Correct Answer: A
Rationale: Crossing the legs post-hip replacement risks dislocation of the prosthesis and should be avoided.
Question 4 of 5
The nurse assesses a client and notes puffy eyelids, swollen ankles, and crackles at both lung bases. The nurse understands that these clinical findings are most specifically associated with fluid excess in which of the following compartments?
Correct Answer: C
Rationale: These symptoms indicate fluid excess in the extracellular compartment, which includes interstitial spaces (edema) and intravascular spaces (contributing to lung crackles).
Question 5 of 5
Carbamazepine is prescribed for the management of generalized tonic-clonic seizures. The nurse instructs the client to inform the primary health care provider if which sign/symptom occurs?
Correct Answer: C
Rationale: Drowsiness, dizziness, nausea, and vomiting are frequent side effects associated with the medication. Adverse reactions include blood dyscrasias. If the client develops a fever, sore throat, mouth ulcerations, unusual bleeding or bruising, or joint pain, this may be indicative of a blood dyscrasia, and the primary health care provider should be notified.