NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
A family member asks to take the client, who is on aneurysm precautions, to the unit lounge for 'just a few minutes.' Which concepts should the nurse use when explaining why the client must remain in the room?
Correct Answer: C
Rationale: Subarachnoid precautions (or aneurysm precautions) are intended to minimize environmental stimuli, which could increase intracranial pressure and trigger bleeding or rupture of the aneurysm. The aneurysm will not heal more rapidly with reduced stimuli. The client does not need isolation to 'cope' with photosensitivity (although photosensitivity may be a problem). No data indicate that the client has disorganization of thoughts and feelings.
Question 2 of 5
A client has started taking amiodarone (Cordarone). The nurse should inform the client that periodic laboratory tests will be done to monitor the client's:
Correct Answer: B
Rationale: Amiodarone can cause hepatotoxicity, so periodic monitoring of liver enzymes is necessary to detect potential liver damage.
Question 3 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 4 of 5
The nurse is caring for a client with a history of gastric bypass surgery. Which of the following vitamins is the client at highest risk for deficiency?
Correct Answer: B
Rationale: Gastric bypass surgery impairs vitamin B12 absorption due to reduced intrinsic factor production, increasing deficiency risk.
Question 5 of 5
A 4-year-old child is admitted with dehydration due to gastroenteritis. Which assessment finding indicates severe dehydration?
Correct Answer: C
Rationale: Sunken fontanelles in a young child are a sign of severe dehydration, indicating significant fluid loss requiring urgent rehydration.