SATA nclex questions and answers
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
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
1,2,3,4
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 Fallot. 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.
2,4,5,6
Rationale:
The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic
episode.
Hypercyanotic episodes often occur among infants with tetralogy of Fallot, and they may occur
among
infants whose heart defect includes the obstruction of pulmonary blood flow and
communication
between the ventricles. If a hypercyanotic 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
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
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
1,2,3,4
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 Fallot. 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.
2,4,5,6
Rationale:
The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic
episode.
Hypercyanotic episodes often occur among infants with tetralogy of Fallot, and they may occur
among
infants whose heart defect includes the obstruction of pulmonary blood flow and
communication
between the ventricles. If a hypercyanotic 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
