{"id":110906,"date":"2023-07-28T14:43:13","date_gmt":"2023-07-28T14:43:13","guid":{"rendered":"https:\/\/learnexams.com\/blog\/?p=110906"},"modified":"2023-07-28T14:43:15","modified_gmt":"2023-07-28T14:43:15","slug":"nclex-pn-sata-well-solved-with-rationales-2023","status":"publish","type":"post","link":"https:\/\/www.learnexams.com\/blog\/2023\/07\/28\/nclex-pn-sata-well-solved-with-rationales-2023\/","title":{"rendered":"NCLEX PN SATA WELL SOLVED WITH RATIONALES 2023"},"content":{"rendered":"\n

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.<\/p>\n\n\n\n

    \n
  1. To avoid activities that require bending over<\/li>\n\n\n\n
  2. To contact the surgeon if eye scratchiness occurs<\/li>\n\n\n\n
  3. To place an eye shield on the surgical eye at bedtime<\/li>\n\n\n\n
  4. That episodes of sudden severe
    pain in the eye is expected<\/li>\n\n\n\n
  5. To contact the surgeon if a decrease in visual acuity occurs<\/li>\n\n\n\n
  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.
    1 \/ 4
    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.<\/li>\n\n\n\n
  7. Administering oxygen<\/li>\n\n\n\n
  8. Inserting a Foley catheter<\/li>\n\n\n\n
  9. Administering furosemide (Lasix)<\/li>\n\n\n\n
  10. Administering morphine sulfate intravenously<\/li>\n\n\n\n
  11. Transporting the client to the coronary care unit<\/li>\n\n\n\n
  12. 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
    2 \/ 4
    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.<\/li>\n\n\n\n
  13. Call a code blue.<\/li>\n\n\n\n
  14. Notify the registered nurse.<\/li>\n\n\n\n
  15. Place the infant in a prone position.<\/li>\n\n\n\n
  16. Prepare to administer morphine sulfate.<\/li>\n\n\n\n
  17. Prepare to administer intravenous fluids.<\/li>\n\n\n\n
  18. 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\u0002chest 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
    3 \/ 4
    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.<\/li>\n\n\n\n
  19. Radiation<\/li>\n\n\n\n
  20. Chemotherapy<\/li>\n\n\n\n
  21. Increased fluid intake<\/li>\n\n\n\n
  22. Serum sodium blood levels<\/li>\n\n\n\n
  23. Decreased oral sodium intake<\/li>\n\n\n\n
  24. Medication that is antagonistic to antidiuretic hormone (ADH)
    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<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"

    The nurse is preparing a teaching plan for a client who is undergoing cataractextraction with intraocularimplant. Which home care measures will the nurse include in the plan? Select all thatapply.<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[],"tags":[],"class_list":["post-110906","post","type-post","status-publish","format-standard","hentry"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/110906","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=110906"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/110906\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=110906"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=110906"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=110906"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}