NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
A 72-year-old client is referred for counseling. During the initial nursing assessment, the client denies the need for counseling. The nurse would agree with the client if she made which of the following comments?
Correct Answer: C
Rationale: Increased energy and activity post-grief suggest the client is coping well, supporting her denial of needing counseling.
Question 2 of 5
You are precepting a new graduate nurse who will be administering an intramuscular injection to an adult client. The new graduate nurse identifies the gluteus maximus muscle by palpating it. What would you do?
Correct Answer: B
Rationale: The vastus lateralis is preferred over the gluteus maximus for IM injections in adults due to lower risk of sciatic nerve injury.
Question 3 of 5
The client has sore nares while a nasogastric (NG) tube is in place. Which of the following nursing measures would be most appropriate to help alleviate the client's discomfort?
Correct Answer: C
Rationale: Applying a water-soluble lubricant to the nares reduces irritation and discomfort caused by the NG tube.
Question 4 of 5
A client who had undergone an abdominal hysterectomy is in the recovery room. The surgeon has ordered a 250-mL bolus of normal saline over 1 hour to replace blood loss. The I.V. solution infusing in the client was 1,000 mL normal saline with 40 mEq of potassium chloride at 100 mL/hour. The nurse should: Select all that apply.
Correct Answer: C,E
Rationale: A separate 250-mL bag via Y-connection and infusion pump ensures accurate delivery of the bolus without altering the primary infusion.
Question 5 of 5
A family member asks to take the client, who is on aneurysm precautions, to the unit lounge for 'just a few minutes.' Which concepts should the nurse use when explaining why the client must remain in the room?
Correct Answer: C
Rationale: Subarachnoid precautions (or aneurysm precautions) are intended to minimize environmental stimuli, which could increase intracranial pressure and trigger bleeding or rupture of the aneurysm. The aneurysm will not heal more rapidly with reduced stimuli. The client does not need isolation to 'cope' with photosensitivity (although photosensitivity may be a problem). No data indicate that the client has disorganization of thoughts and feelings.