NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
A client is admitted to the hospital after sustaining a fall from a roof. The client has multiple lacerations and a right leg fracture, which has been treated with a plaster cast. How should the nurse position the client's leg to promote optimal circulation?
Correct Answer: D
Rationale: A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and promote venous drainage. The other options are not part of standard positioning of the newly casted extremity.
Question 2 of 5
The nurse is delivering care to a client who is diagnosed with toxic shock syndrome (TSS). Which complication of this syndrome should the nurse monitor the client for?
Correct Answer: D
Rationale: TSS is caused by infection and is often associated with tampon use. DIC is a complication of TSS. The nurse monitors the client for signs of this complication, and notifies the primary health care provider promptly if signs and symptoms are noted. The other options are not complications of TSS.
Question 3 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.
Question 4 of 5
A 13-year-old client is dying of cancer and struggling with the emotional aspects of this. When providing care for this client, the nurse should incorporate the developmental tasks for this age. According to Erikson's developmental model, the child normally is expected to be working on which of the following psychosocial issues?
Correct Answer: A
Rationale: Adolescents (ages 12–18) focus on identity vs. role confusion, developing a sense of self and personal identity.
Question 5 of 5
The nurse is teaching a client about the use of a peak flow meter for asthma management. The client should be instructed to:
Correct Answer: B
Rationale: Recording the highest of three peak flow readings provides the most accurate assessment of lung function for asthma monitoring.