NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
A 10-month-old child has cold symptoms. The mother asks how she can clear the infant's nose. Which of the following would be the nurse's best recommendation?
Correct Answer: B
Rationale: Saline nose drops followed by bulb syringe suction is safe and effective for clearing nasal congestion in infants. Vaporizers help with humidity, but saline and suction directly clear the nose.
Question 2 of 5
A client on a psychiatric care unit approaches the nurse and complains of muscle spasms in his neck, stiffness in other muscles, and that his eyes are rolling upward. The client had two p.r.n. doses of haloperidol (Haldol) in the last 6 hours. Of the drugs that have been ordered for the client as needed (see chart), the nurse should administer:
Correct Answer: D
Rationale: Dystonic adverse effects of haloperidol, especially oculogyric crises, are painful and frightening. I.M. benztropine is the fastest and most effective drug for managing dystonia. Lorazepam is an antianxiety medication and is not effective for treatment of dystonia. Although amantadine and diphenhydramine can be used for extrapyramidal symptoms, oral medications do not work as quickly, and amantadine may worsen psychotic symptoms.
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 provides instructions to a client who is taking allopurinol for the treatment of gout. Which statement by the client indicates an understanding of the medication?
Correct Answer: C
Rationale: Clients taking allopurinol are encouraged to drink 3000 mL of fluid a day. If the client develops a rash, irritation of the eyes, or swelling of the lips or mouth, he or she should contact the primary health care provider because this may indicate hypersensitivity. Allopurinol is to be given with or immediately after meals or milk.
Question 5 of 5
During your system specific assessment of your client's peripheral pulses, you note that the client's posterior tibia pulse is weak and thready. You would document this finding as:
Correct Answer: C
Rationale: A weak and thready pulse is documented as 1+ on a 0-4+ scale, indicating diminished pulse strength.