NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
A client has been hospitalized with heart failure. He is receiving digoxin (Lanoxin) and furosemide (Lasix) intravenously. He tells the nurse that he hears a continuous ringing in his ears and that he has never had this problem before. What is the appropriate action for the nurse to take at this time?
Correct Answer: A
Rationale: Ringing in the ears (tinnitus) is a sign of digoxin toxicity, requiring immediate checking of digoxin levels. Aspirin is less likely to cause this, and discontinuing furosemide or delaying action is inappropriate.
Question 2 of 5
The nurse is to administer a bolus starting dose of heparin to a child who is taking penicillin. What should the nurse do? Select all that apply.
Correct Answer: A,C,D
Rationale: Verifying the dose, administering a maintenance infusion, and monitoring PTT are standard for heparin therapy. Heparin's onset is immediate for I.V. but not a primary concern. Penicillin does not need discontinuation.
Question 3 of 5
Which manifestations associated with thyroid storm indicate the need for immediate nursing intervention?
Correct Answer: C
Rationale: The excessive amounts of thyroid hormone cause a rapid increase in the metabolic rate, thereby causing the manifestations of thyroid storm such as fever, tachycardia, and hypertension. When these signs present themselves, the nurse must take quick action to prevent deterioration of the client's health because death can ensue. Priority interventions include maintaining a patent airway and stabilizing the hemodynamic status. The remaining options do not indicate the need for immediate nursing intervention nor are they associated with thyroid storm.
Question 4 of 5
After 2 days on a psychiatric unit, a client is still isolating himself in his room, except for meals. The client says he is uncomfortable around crowds of people. Which nursing intervention is the most appropriate initially?
Correct Answer: C
Rationale: A walk with the nurse and one other client provides a low-pressure social interaction, helping the client gradually build comfort with others while respecting his anxiety about crowds.
Question 5 of 5
The nurse is discharging a client who has been hospitalized for preterm labor. The client needs further instruction when she says:
Correct Answer: D
Rationale: Clients with preterm labor should get out of the car every 1-2 hours to promote circulation and prevent complications, not every 4 hours, indicating a need for further instruction.