NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 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 2 of 5
After 2 days on a psychiatric unit, a client is still isolating himself in his room, except for meals. The client says he is uncomfortable around crowds of people. Which nursing intervention is the most appropriate initially?
Correct Answer: C
Rationale: A walk with the nurse and one other client provides a low-pressure social interaction, helping the client gradually build comfort with others while respecting his anxiety about crowds.
Question 3 of 5
A 10-month-old child has cold symptoms. The mother asks how she can clear the infant's nose. Which of the following would be the nurse's best recommendation?
Correct Answer: B
Rationale: Saline nose drops followed by bulb syringe suction is safe and effective for clearing nasal congestion in infants. Vaporizers help with humidity, but saline and suction directly clear the nose.
Question 4 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 5 of 5
Which of the following is an effective security plan that you may most likely want to consider for implementation within your facility?
Correct Answer: C,D
Rationale: Restricting visitors in special care areas and using bar-coded client identification bands are effective security measures to enhance safety and protect client identity, respectively.