NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
A client has received electroconvulsive therapy (ECT). What intervention should the nurse perform first in the posttreatment area and upon the client's awakening?
Correct Answer: B
Rationale: The nurse should first monitor vital signs, orient the client, and review with the client that he or she just received an ECT treatment. The posttreatment area should include accessibility to the anesthesia staff, oxygen, suction, pulse oximeter, vital sign monitoring, and emergency equipment. The nursing interventions outlined in the remaining options will follow accordingly.
Question 2 of 5
The nurse is assessing the leg pain of a client who has just undergone right femoral-popliteal artery bypass grafting. Which question would be most useful in determining whether the client is experiencing graft occlusion?
Correct Answer: D
Rationale: The most frequent indication that a graft is occluding is the return of pain that is similar to that experienced preoperatively. Standard pain assessment techniques also include the items described in the remaining options, but these will not help differentiate current pain from preoperative pain.
Question 3 of 5
The client received electroconvulsive therapy (ECT) an hour ago and tells the nurse that he has a headache. Which response by the nurse is best?
Correct Answer: B
Rationale: Offering acetaminophen addresses the client's complaint directly and safely, as headaches are a common side effect of ECT. Informing the client that headaches are common does not provide relief, and a nap or unclear commands are not appropriate responses.
Question 4 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 5 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.