NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
A client with a history of seizures is prescribed phenytoin (Dilantin). The nurse should instruct the client to report which of the following side effects?
Correct Answer: A
Rationale: Phenytoin commonly causes gingival hyperplasia, which should be reported to manage oral health and adjust treatment if needed.
Question 2 of 5
On the first postpartum day, the nurse is caring for a primiparous client who has recently emigrated from Japan to the United States and speaks only a little English. The nurse observes that the client has been bottle-feeding her neonate on occasion, but most of the neonatal care is being performed by the client's mother-in-law. Which of the following actions would be most appropriate?
Correct Answer: C
Rationale: Assessing whether the mother-in-law's involvement is a cultural practice respects the client's background and avoids misjudging normal family dynamics.
Question 3 of 5
A client has massive bleeding from esophageal varices. In what order should the nurse and care team provide care for this client?
Order the Items
Source Container
Correct Answer: D, A, B, C
Rationale: The priority is to maintain a patent airway, control hemorrhaging, replace fluids, and then address anxiety to stabilize the client.
Question 4 of 5
A client with a history of type 2 diabetes mellitus is prescribed metformin (Glucophage). The nurse should instruct the client to report which of the following side effects immediately?
Correct Answer: C
Rationale: Lactic acidosis is a rare but serious side effect of metformin, requiring immediate reporting of symptoms like muscle pain or weakness.
Question 5 of 5
A family has been notified that their son is brain dead, and the physician has discussed the possibility of donating organs. The nurse should collaborate with the physician to contact which referral source that is responsible for organ recovery in the United States?
Correct Answer: A
Rationale: Organ and Tissue Procurement Organizations are responsible for coordinating organ recovery in the United States, as they manage the donation process and ensure compliance with regulations.