NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
A client is reporting skin irritation from the edges of a cast that was applied the previous day. The nurse notes that the skin is pink and irritated. Which corrective action should the nurse take?
Correct Answer: A
Rationale: The nurse should petal the edges of the cast with tape to minimize skin irritation. Massaging the skin will not help the problem. Powder should not be shaken under the cast because it could clump, become moist, and cause skin breakdown. A hair dryer is used on a cool low setting if a nonplaster cast becomes wet or if the client's skin itches under a cast.
Question 2 of 5
A primiparous client at 48 hours postpartum is to be given medroxyprogesterone acetate (Depo-Provera) before discharge. Which of the following should the nurse include in the teaching plan before administering this medication?
Correct Answer: B
Rationale: Amenorrhea is a common side effect of Depo-Provera, especially in the first 6 months, and should be included in client teaching. The other options are incorrect.
Question 3 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 4 of 5
The physician orders I.V. cefazolin (Kefzol) 1g for a client. In preparing to administer the Kefzol, the nurse notes that the client is allergic to penicillin. Based on this information, what is an appropriate action for the nurse to take?
Correct Answer: B
Rationale: Cefazolin, a cephalosporin, has a risk of cross-reactivity in penicillin-allergic clients, so the nurse should notify the physician to consider an alternative. Administering or verifying with the pharmacist without physician consultation is unsafe.
Question 5 of 5
The nurse is evaluating the pin insertion site of a client's skeletal traction. Which of the following indicate a complication?
Correct Answer: C
Rationale: A moving pin indicates instability, a complication risking infection or poor healing. Crusts and serous drainage are normal, and lack of pain is not a complication.