NCLEX RN Select All That Apply (SATA) Test with
Answers
A nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects
data from the client and notes which of the following signs supports this diagnosis? Select all
that apply.
A. Scant mucus
B. Early onset cough
C. Marked weight loss
D. Purulent mucus production
E. Mild episodes of
dyspnea Correct Answer:
B, D, & E.
Key features of pulmonary emphysema include dyspnea that is often marked, late cough (after
the onset of dyspnea), scant mucus production, and marked weight loss. By contrast, chronic
bronchitis is characterized by an early onset of cough (before dyspnea), copious purulent mucus
production, minimal weight loss, and milder severity of dyspnea.
Option A: Most patients with emphysema present with very nonspecific symptoms of chronic
shortness of breath and cough with or without sputum production. As the disease process
advances, the shortness of breath and cough progressively get worse.
Option B: The most common symptom of patients with chronic bronchitis is a cough. The
history of a cough typical of chronic bronchitis is characterized to be present for most days in a
month lasting for 3 months with at least 2 such episodes occurring for 2 years in a row. The
characteristic cough of bronchitis is caused by the copious secretion of mucus in chronic
bronchitis.
Option C: As COPD advances, patients can lose significant body weight due to systemic
inflammation and increased energy spent in the work of breathing. Also, there are frequent
intermittent exacerbations as the obstruction of the airways increases.
,Option D: The airways become clogged by debris and this further increases the irritation. A
productive cough with sputum is present in about 50% of patients. The sputum color may vary
from clear, yellow, green, or at times blood-tinged. The color of the sputum may be dependent
on the presence of secondary bacterial infection.
Option E: During an acute exacerbation of chronic bronchitis, the bronchial mucous membrane
becomes hyperemic and edematous with diminished bronchial mucociliary function. This, in
turn, leads to airflow impediment because of luminal obstruction to small airways.
,A nurse, assigned to a client with emphysema, is providing a shift report. Which nursing
interventions would be appropriate to include? Select all that apply.
A. The nurse should reduce fluid intake to less than 850 ml per shift.
B. The nurse should teach diaphragmatic, pursed-lip breathing.
C. The nurse should administer low-flow oxygen.
D. The nurse should keep the client in a supine position as much as possible.
E. The nurse should encourage alternating activity with rest periods.
F. The nurse should teach the use of postural drainage and chest
physiotherapy. Correct Answer: B, C, E, & F.
Emphysema is the most severe form of COPD, characterized by recurrent inflammation that
damages and eventually destroys alveolar walls to create large blebs or bullae (air spaces) and
collapsed bronchioles on expiration (air-trapping).
Option A: Fluid intake should be increased to 3,000 ml/day, if not contraindicated, to liquefy
secretions and facilitate their removal. Provide warm or tepid liquids. Recommend the intake of
fluids between, instead of during, meals. Using warm liquids may decrease bronchospasm.
Fluids during meals can increase gastric distension and pressure on the diaphragm.
Option B: Diaphragmatic, pursed-lip breathing strengthens respiratory muscles and enhances
oxygenation in clients with emphysema. This provides the client with some means to cope with
or control dyspnea and reduce air-trapping.
Option C: Low-flow oxygen should be administered because a client with emphysema has
chronic hypercapnia and a hypoxic respiratory drive. Administering humidified oxygen prevents
drying out the airways, decreases convective moisture losses, and improves compliance.
Option D: The client should be placed in high Fowler’s position to improve ventilation.
Elevation of the head of the bed facilitates respiratory function by use of gravity; however, the
client in severe distress will seek the position that most eases breathing.
Option E: Alternating activity with rest allows to perform activities without excessive distress.
During severe, acute or refractory respiratory distress, the patient may be totally unable to
perform basic self- care activities because of hypoxemia and dyspnea. Rest interspersed with
care activities remains an important part of the treatment regimen.
Option F: If the client has difficulty mobilizing copious secretions, the nurse should teach the
client and family members how to perform postural drainage and chest physiotherapy. These
techniques will prevent possible aspirations and prevent any untoward complications.
, A nurse is assigned to care for a client with a peripheral IV infusion. The nurse is providing
hygiene care to the client and would avoid which of the following while changing the client’s
hospital gown?
A. Using a hospital gown with snaps at the sleeves
B. Disconnecting the IV tubing from the catheter in the vein
C. Checking the IV flow rate immediately after changing the hospital gown
D. Putting the bag and tubing through the sleeve, followed by the client’s arm
E. Keeping splint soiled by blood or fluid leakage
Correct Answer: B & E.
Changing a patient’s hospital gown is needed to maintain their cleanliness and the feeling of
freshness.
Option A: A kimono-inspired gown opens in the front and uses a system of ties and snaps at
essential access points for easy treatment and monitoring. Top snaps offer upper back access.
Wide sleeves and side snaps provide easy access for an I.V., and are MRI-compatible.
Option B: The tubing should not be removed from the IV catheter. With each break in the
system, there is an increased chance of introducing bacteria into the system, which can lead to
infection.
Option C: The flow rate should be checked immediately after changing the hospital gown,
because the position of the roller clamp may have been affected during the change. Count the
rate of flow of the infusion to make sure it is correct before leaving the bedside.
Option D: Holding the container above the client’s arm, slide the sleeve up over the container to
remove the used gown. Place the clean gown sleeve for the arm with the infusion over the
container as if it were an extension of the client’s arm, from the inside of the gown to the sleeve
cuff.
Option E: IV board/splints are recommended to secure PIVC placed in or adjacent to areas of
flexion. This will adequately immobilize the joint and minimize the risk of venous damage
resulting from flexion.
Splints should be Inspected at least daily and change if soiled by blood or fluid
leakage.
Answers
A nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects
data from the client and notes which of the following signs supports this diagnosis? Select all
that apply.
A. Scant mucus
B. Early onset cough
C. Marked weight loss
D. Purulent mucus production
E. Mild episodes of
dyspnea Correct Answer:
B, D, & E.
Key features of pulmonary emphysema include dyspnea that is often marked, late cough (after
the onset of dyspnea), scant mucus production, and marked weight loss. By contrast, chronic
bronchitis is characterized by an early onset of cough (before dyspnea), copious purulent mucus
production, minimal weight loss, and milder severity of dyspnea.
Option A: Most patients with emphysema present with very nonspecific symptoms of chronic
shortness of breath and cough with or without sputum production. As the disease process
advances, the shortness of breath and cough progressively get worse.
Option B: The most common symptom of patients with chronic bronchitis is a cough. The
history of a cough typical of chronic bronchitis is characterized to be present for most days in a
month lasting for 3 months with at least 2 such episodes occurring for 2 years in a row. The
characteristic cough of bronchitis is caused by the copious secretion of mucus in chronic
bronchitis.
Option C: As COPD advances, patients can lose significant body weight due to systemic
inflammation and increased energy spent in the work of breathing. Also, there are frequent
intermittent exacerbations as the obstruction of the airways increases.
,Option D: The airways become clogged by debris and this further increases the irritation. A
productive cough with sputum is present in about 50% of patients. The sputum color may vary
from clear, yellow, green, or at times blood-tinged. The color of the sputum may be dependent
on the presence of secondary bacterial infection.
Option E: During an acute exacerbation of chronic bronchitis, the bronchial mucous membrane
becomes hyperemic and edematous with diminished bronchial mucociliary function. This, in
turn, leads to airflow impediment because of luminal obstruction to small airways.
,A nurse, assigned to a client with emphysema, is providing a shift report. Which nursing
interventions would be appropriate to include? Select all that apply.
A. The nurse should reduce fluid intake to less than 850 ml per shift.
B. The nurse should teach diaphragmatic, pursed-lip breathing.
C. The nurse should administer low-flow oxygen.
D. The nurse should keep the client in a supine position as much as possible.
E. The nurse should encourage alternating activity with rest periods.
F. The nurse should teach the use of postural drainage and chest
physiotherapy. Correct Answer: B, C, E, & F.
Emphysema is the most severe form of COPD, characterized by recurrent inflammation that
damages and eventually destroys alveolar walls to create large blebs or bullae (air spaces) and
collapsed bronchioles on expiration (air-trapping).
Option A: Fluid intake should be increased to 3,000 ml/day, if not contraindicated, to liquefy
secretions and facilitate their removal. Provide warm or tepid liquids. Recommend the intake of
fluids between, instead of during, meals. Using warm liquids may decrease bronchospasm.
Fluids during meals can increase gastric distension and pressure on the diaphragm.
Option B: Diaphragmatic, pursed-lip breathing strengthens respiratory muscles and enhances
oxygenation in clients with emphysema. This provides the client with some means to cope with
or control dyspnea and reduce air-trapping.
Option C: Low-flow oxygen should be administered because a client with emphysema has
chronic hypercapnia and a hypoxic respiratory drive. Administering humidified oxygen prevents
drying out the airways, decreases convective moisture losses, and improves compliance.
Option D: The client should be placed in high Fowler’s position to improve ventilation.
Elevation of the head of the bed facilitates respiratory function by use of gravity; however, the
client in severe distress will seek the position that most eases breathing.
Option E: Alternating activity with rest allows to perform activities without excessive distress.
During severe, acute or refractory respiratory distress, the patient may be totally unable to
perform basic self- care activities because of hypoxemia and dyspnea. Rest interspersed with
care activities remains an important part of the treatment regimen.
Option F: If the client has difficulty mobilizing copious secretions, the nurse should teach the
client and family members how to perform postural drainage and chest physiotherapy. These
techniques will prevent possible aspirations and prevent any untoward complications.
, A nurse is assigned to care for a client with a peripheral IV infusion. The nurse is providing
hygiene care to the client and would avoid which of the following while changing the client’s
hospital gown?
A. Using a hospital gown with snaps at the sleeves
B. Disconnecting the IV tubing from the catheter in the vein
C. Checking the IV flow rate immediately after changing the hospital gown
D. Putting the bag and tubing through the sleeve, followed by the client’s arm
E. Keeping splint soiled by blood or fluid leakage
Correct Answer: B & E.
Changing a patient’s hospital gown is needed to maintain their cleanliness and the feeling of
freshness.
Option A: A kimono-inspired gown opens in the front and uses a system of ties and snaps at
essential access points for easy treatment and monitoring. Top snaps offer upper back access.
Wide sleeves and side snaps provide easy access for an I.V., and are MRI-compatible.
Option B: The tubing should not be removed from the IV catheter. With each break in the
system, there is an increased chance of introducing bacteria into the system, which can lead to
infection.
Option C: The flow rate should be checked immediately after changing the hospital gown,
because the position of the roller clamp may have been affected during the change. Count the
rate of flow of the infusion to make sure it is correct before leaving the bedside.
Option D: Holding the container above the client’s arm, slide the sleeve up over the container to
remove the used gown. Place the clean gown sleeve for the arm with the infusion over the
container as if it were an extension of the client’s arm, from the inside of the gown to the sleeve
cuff.
Option E: IV board/splints are recommended to secure PIVC placed in or adjacent to areas of
flexion. This will adequately immobilize the joint and minimize the risk of venous damage
resulting from flexion.
Splints should be Inspected at least daily and change if soiled by blood or fluid
leakage.
