NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
A client on a psychiatric care unit approaches the nurse and complains of muscle spasms in his neck, stiffness in other muscles, and that his eyes are rolling upward. The client had two p.r.n. doses of haloperidol (Haldol) in the last 6 hours. Of the drugs that have been ordered for the client as needed (see chart), the nurse should administer:
Correct Answer: D
Rationale: Dystonic adverse effects of haloperidol, especially oculogyric crises, are painful and frightening. I.M. benztropine is the fastest and most effective drug for managing dystonia. Lorazepam is an antianxiety medication and is not effective for treatment of dystonia. Although amantadine and diphenhydramine can be used for extrapyramidal symptoms, oral medications do not work as quickly, and amantadine may worsen psychotic symptoms.
Question 2 of 5
The nurse is evaluating the client's potential for development of a pressure sore. Which of the following individual characteristics would be the best indicator of risk for the client's developing a pressure sore?
Correct Answer: C
Rationale: Immobility is the primary risk factor for pressure sores, as it leads to prolonged pressure on tissues.
Question 3 of 5
A client with a new diagnosis of hypothyroidism is prescribed levothyroxine. What should the nurse include in the teaching plan?
Correct Answer: C
Rationale: Palpitations or chest pain may indicate overmedication or cardiac effects, requiring prompt reporting to adjust the levothyroxine dose.
Question 4 of 5
A client with a diagnosis of hyperthyroidism is prescribed propylthiouracil (PTU). The nurse should monitor the client for which of the following side effects?
Correct Answer: B
Rationale: Propylthiouracil can cause agranulocytosis, requiring monitoring of white blood cell counts.
Question 5 of 5
A client who had undergone an abdominal hysterectomy is in the recovery room. The surgeon has ordered a 250-mL bolus of normal saline over 1 hour to replace blood loss. The I.V. solution infusing in the client was 1,000 mL normal saline with 40 mEq of potassium chloride at 100 mL/hour. The nurse should: Select all that apply.
Correct Answer: C,E
Rationale: A separate 250-mL bag via Y-connection and infusion pump ensures accurate delivery of the bolus without altering the primary infusion.