NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
A client with a paranoid personality disorder sees some clients laughing during a group activity and asks the nurse, 'Why are they laughing at me? I bet they're making fun of me.' Which of the following responses by the nurse is most appropriate?
Correct Answer: D
Rationale: Providing a factual explanation that the laughter is due to a joke addresses the client's paranoia directly and reassuringly, reducing misinterpretation. Other responses dismiss or minimize the client's feelings.
Question 2 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.
Question 3 of 5
A Hispanic client is admitted to the surgical unit from the emergency department for an appendectomy. The nurse conducts the preoperative preparations and determines that the client has difficulty understanding English. The surgeon needs to obtain the client's informed consent. The nurse course for obtaining the client's informed consent is to:
Correct Answer: C
Rationale: The surgeon is required to give the client explanations and have questions answered. The nurse has no way of assessing the client's understanding without the interpreter. The client should sign the Spanish consent form only after receiving an explanation of the procedure, its risks, and alternatives. A family member cannot be relied on to translate the surgeon's instructions accurately.
Question 4 of 5
The nurse is caring for a client who has just undergone a liver biopsy. Which of the following interventions is most important in the immediate post-procedure period?
Correct Answer: A
Rationale: Keeping the client on the right side for 2 hours post-liver biopsy applies pressure to the site, reducing the risk of bleeding.
Question 5 of 5
The nurse is assessing a client with irreversible shock. The nurse should document which of the following?
Correct Answer: B
Rationale: Irreversible shock is characterized by circulatory collapse, with failure of vital organs due to inadequate perfusion, a critical finding to document.