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 with a history of schizophrenia is prescribed clozapine (Clozaril). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Clozapine can cause agranulocytosis, requiring regular white blood cell monitoring.
Question 3 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 4 of 5
Your client has a doctor's order for the antihistamine medication diphenhydramine for sleep. What should you do?
Correct Answer: D
Rationale: Diphenhydramine (Benadryl) is commonly used off-label for sleep due to its sedative effects, making it an appropriate choice if ordered for this purpose.
Question 5 of 5
What is the primary goal of nursing care during the emergent phase after a burn injury?
Correct Answer: A
Rationale: Replacing lost fluids is the primary goal in the emergent phase to prevent hypovolemic shock due to fluid loss from burns.