NCLEX SATA Exam Practice | NCLEX Select All
That Apply Questions | SATA NCLEX Rationales
The nurse is preparing a teaching plan for a client who is undergoing cataract extraction
with intraocular
implant. Which home care measures will the nurse include in the plan? Select all that
apply.
1. To avoid activities that require bending over
2. To contact the surgeon if eye scratchiness occurs
3. To place an eye shield on the surgical eye at bedtime
4. That episodes of sudden severe
pain in the eye is expected
5. To contact the surgeon if a decrease in visual acuity occurs
6. To take acetaminophen (Tylenol) for minor eye discomfort - ANSWER-1,3,5,6
Rationale:
After eye surgery, some scratchiness and mild eye discomfort may occur in the
operative eye and is
usually relieved by mild analgesics. If the eye pain becomes severe, the client should
notify the surgeon
because this may indicate hemorrhage, infection, or increased intraocular pressure. The
nurse would also
instruct the client to notify the surgeon of purulent drainage, increased redness, or any
decrease in visual
acuity. The client is instructed to place an eye shield over the operative eye at bedtime
to protect the eye
from injury during sleep and to avoid activities that increase intraocular pressure such
as bending over.
A nurse in a medical unit is caring for a client with heart failure. The client suddenly
develops extreme
dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema.
The nurse immediately
notifies the registered nurse and expects which interventions to be prescribed? Select
all that apply.
1. Administering oxygen
2. Inserting a Foley catheter
3. Administering furosemide (Lasix)
4. Administering morphine sulfate intravenously
5. Transporting the client to the coronary care unit
6. Placing the client in a low Fowler's side-lying position - ANSWER-1,2,3,4
Page 1 of 28
,Rationale:
Pulmonary edema is a life-threatening event that can result from severe heart failure. In
pulmonary
edema the left ventricle fails to eject sufficient blood, and pressure increases in the
lungs because of the
accumulated blood. Oxygen is always prescribed, and the client is placed in a high
Fowler's position to
ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate
accumulated fluid. A Foley
catheter is inserted to accurately measure output. Intravenously administered morphine
sulfate reduces
venous return (preload), decreases anxiety, and reduces the work of breathing.
Transporting the client to
the coronary care unit is not a priority intervention. In fact, this may not be necessary at
all if the client's
response to treatment is successful
A nurse is caring for an infant with a diagnosis of tetralogy of Fallout. The infant
suddenly becomes
cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that
the nurse should
perform. Select all that apply.
1. Call a code blue.
2. Notify the registered nurse.
3. Place the infant in a prone position.
4. Prepare to administer morphine sulfate.
5. Prepare to administer intravenous fluids.
6. Prepare to administer 100% oxygen by face mask. - ANSWER-2,4,5,6
Rationale:
The child who is cyanotic with oxygen saturations dropping to 60% is having a hyper
cyanotic episode.
Hyper cyanotic episodes often occur among infants with tetralogy of Fallout, and they
may occur among
infants whose heart defect includes the obstruction of pulmonary blood flow and
communication
between the ventricles. If a hyper cyanotic episode occurs, the infant is placed in a
knee-chest position
immediately. The registered nurse is notified, who will then contact the health care
provider. The knee-
chest position improves systemic arterial oxygen saturation by decreasing venous
return so that smaller
amounts of highly saturated blood reach the heart. Toddlers and children squat to get
into this position
and relieve chronic hypoxia. There is no reason to call a code blue unless respirations
cease. Additional
Page 2 of 28
, interventions include administering 100% oxygen by face mask, morphine sulfate, and
intravenous fluids,
as prescribed.
A client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic
hormone
(SIADH) as a complication of the cancer. The nurse anticipates that which of the
following may be
prescribed? Select all that apply.
1. Radiation
2. Chemotherapy
3. Increased fluid intake
4. Serum sodium blood levels
5. Decreased oral sodium intake
6. Medication that is antagonistic to antidiuretic hormone (ADH) - ANSWER-1,2,4,6
Rationale:
Cancer is a common cause of SIADH. In clients with SIADH, excessive amounts of
water are reabsorbed
by the kidney and put into the systemic circulation. The increased water causes
hyponatremia (decreased
serum sodium levels) and some degree of fluid retention. SIADH is managed by treating
the condition
and its cause, and treatment usually includes fluid restriction, increased sodium intake,
and a medication
with a mechanism of action that is antagonistic to ADH. Sodium levels are monitored
closely, because
hypernatremia can suddenly develop as a result of treatment. The immediate institution
of appropriate
cancer therapy (usually either radiation or chemotherapy) can cause tumor regression
so that ADH
synthesis and release processes return to normal.
A nurse prepares a list of home care instructions for the parents of a child who has a
plaster cast applied
to the left forearm. Choose the instructions that would be included on the list. Select all
that apply.
1. Use the fingertips to lift the cast while it is drying.
2. Keep small toys and sharp objects away from the cast.
3. Use a padded ruler or another padded object to scratch the skin under the cast if it
itches.
4. Place a heating pad on the lower end of the cast and over the fingers if the fingers
feel cold.
5. Contact the health care provider if the child complains of numbness or tingling in the
extremity.
Page 3 of 28
That Apply Questions | SATA NCLEX Rationales
The nurse is preparing a teaching plan for a client who is undergoing cataract extraction
with intraocular
implant. Which home care measures will the nurse include in the plan? Select all that
apply.
1. To avoid activities that require bending over
2. To contact the surgeon if eye scratchiness occurs
3. To place an eye shield on the surgical eye at bedtime
4. That episodes of sudden severe
pain in the eye is expected
5. To contact the surgeon if a decrease in visual acuity occurs
6. To take acetaminophen (Tylenol) for minor eye discomfort - ANSWER-1,3,5,6
Rationale:
After eye surgery, some scratchiness and mild eye discomfort may occur in the
operative eye and is
usually relieved by mild analgesics. If the eye pain becomes severe, the client should
notify the surgeon
because this may indicate hemorrhage, infection, or increased intraocular pressure. The
nurse would also
instruct the client to notify the surgeon of purulent drainage, increased redness, or any
decrease in visual
acuity. The client is instructed to place an eye shield over the operative eye at bedtime
to protect the eye
from injury during sleep and to avoid activities that increase intraocular pressure such
as bending over.
A nurse in a medical unit is caring for a client with heart failure. The client suddenly
develops extreme
dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema.
The nurse immediately
notifies the registered nurse and expects which interventions to be prescribed? Select
all that apply.
1. Administering oxygen
2. Inserting a Foley catheter
3. Administering furosemide (Lasix)
4. Administering morphine sulfate intravenously
5. Transporting the client to the coronary care unit
6. Placing the client in a low Fowler's side-lying position - ANSWER-1,2,3,4
Page 1 of 28
,Rationale:
Pulmonary edema is a life-threatening event that can result from severe heart failure. In
pulmonary
edema the left ventricle fails to eject sufficient blood, and pressure increases in the
lungs because of the
accumulated blood. Oxygen is always prescribed, and the client is placed in a high
Fowler's position to
ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate
accumulated fluid. A Foley
catheter is inserted to accurately measure output. Intravenously administered morphine
sulfate reduces
venous return (preload), decreases anxiety, and reduces the work of breathing.
Transporting the client to
the coronary care unit is not a priority intervention. In fact, this may not be necessary at
all if the client's
response to treatment is successful
A nurse is caring for an infant with a diagnosis of tetralogy of Fallout. The infant
suddenly becomes
cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that
the nurse should
perform. Select all that apply.
1. Call a code blue.
2. Notify the registered nurse.
3. Place the infant in a prone position.
4. Prepare to administer morphine sulfate.
5. Prepare to administer intravenous fluids.
6. Prepare to administer 100% oxygen by face mask. - ANSWER-2,4,5,6
Rationale:
The child who is cyanotic with oxygen saturations dropping to 60% is having a hyper
cyanotic episode.
Hyper cyanotic episodes often occur among infants with tetralogy of Fallout, and they
may occur among
infants whose heart defect includes the obstruction of pulmonary blood flow and
communication
between the ventricles. If a hyper cyanotic episode occurs, the infant is placed in a
knee-chest position
immediately. The registered nurse is notified, who will then contact the health care
provider. The knee-
chest position improves systemic arterial oxygen saturation by decreasing venous
return so that smaller
amounts of highly saturated blood reach the heart. Toddlers and children squat to get
into this position
and relieve chronic hypoxia. There is no reason to call a code blue unless respirations
cease. Additional
Page 2 of 28
, interventions include administering 100% oxygen by face mask, morphine sulfate, and
intravenous fluids,
as prescribed.
A client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic
hormone
(SIADH) as a complication of the cancer. The nurse anticipates that which of the
following may be
prescribed? Select all that apply.
1. Radiation
2. Chemotherapy
3. Increased fluid intake
4. Serum sodium blood levels
5. Decreased oral sodium intake
6. Medication that is antagonistic to antidiuretic hormone (ADH) - ANSWER-1,2,4,6
Rationale:
Cancer is a common cause of SIADH. In clients with SIADH, excessive amounts of
water are reabsorbed
by the kidney and put into the systemic circulation. The increased water causes
hyponatremia (decreased
serum sodium levels) and some degree of fluid retention. SIADH is managed by treating
the condition
and its cause, and treatment usually includes fluid restriction, increased sodium intake,
and a medication
with a mechanism of action that is antagonistic to ADH. Sodium levels are monitored
closely, because
hypernatremia can suddenly develop as a result of treatment. The immediate institution
of appropriate
cancer therapy (usually either radiation or chemotherapy) can cause tumor regression
so that ADH
synthesis and release processes return to normal.
A nurse prepares a list of home care instructions for the parents of a child who has a
plaster cast applied
to the left forearm. Choose the instructions that would be included on the list. Select all
that apply.
1. Use the fingertips to lift the cast while it is drying.
2. Keep small toys and sharp objects away from the cast.
3. Use a padded ruler or another padded object to scratch the skin under the cast if it
itches.
4. Place a heating pad on the lower end of the cast and over the fingers if the fingers
feel cold.
5. Contact the health care provider if the child complains of numbness or tingling in the
extremity.
Page 3 of 28
