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 parent reports that her child has developed a bloody nose. Which action should the nurse instruct the parent to take to control the bleeding?
Correct Answer: D
Rationale: The child should be positioned erect, sitting with head tilted forward to avoid blood dripping posteriorly to the pharynx. The soft part of the nose should be tightly pinched against the center wall for 10 minutes, and the parent should be instructed that this pinch should be timed by a clock, not estimated. The parent should be told not to release pressure for 10 minutes. The child is encouraged to remain calm and quiet and to breathe through the mouth.
Question 3 of 5
You have loosely applied a bed sheet around your client's waist to prevent a fall from the chair. What have you done?
Correct Answer: D
Rationale: Applying a bed sheet around the client's waist without a proper restraint order constitutes an illegal restraint, which is a crime , as it restricts freedom without proper authorization or consent.
Question 4 of 5
The nurse is assessing a client with a suspected appendicitis. Which of the following findings is most indicative of this condition?
Correct Answer: A
Rationale: Right lower quadrant pain is a hallmark sign of appendicitis due to localized peritoneal irritation.
Question 5 of 5
A client with cirrhosis is admitted with ascites. The nurse should monitor the client for which of the following complications?
Correct Answer: A
Rationale: Ascites can cause diaphragmatic compression, leading to respiratory distress, which requires monitoring.