NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
A school-age child diagnosed with attention deficit hyperactivity disorder is prescribed methylphenidate (Ritalin). Which of the following should alert the school nurse to the possibility that the child is experiencing a common side effect of the drug?
Correct Answer: A
Rationale: Loss of appetite is a common side effect of methylphenidate, often leading to weight loss. Vomiting and photosensitivity are less common, and weight gain is not typical.
Question 2 of 5
A client is receiving total parenteral nutrition (TPN). The nurse notices that the bag of TPN solution has been infusing for 24 hours but has $300 \mathrm{~mL}$ of solution left. The nurse should:
Correct Answer: D
Rationale: TPN solutions should not hang for more than 24 hours due to infection risk. The nurse should discontinue the current bag, change the tubing, and hang a new bag. Continuing or altering the rate is unsafe.
Question 3 of 5
Which manifestations associated with thyroid storm indicate the need for immediate nursing intervention?
Correct Answer: C
Rationale: The excessive amounts of thyroid hormone cause a rapid increase in the metabolic rate, thereby causing the manifestations of thyroid storm such as fever, tachycardia, and hypertension. When these signs present themselves, the nurse must take quick action to prevent deterioration of the client's health because death can ensue. Priority interventions include maintaining a patent airway and stabilizing the hemodynamic status. The remaining options do not indicate the need for immediate nursing intervention nor are they associated with thyroid storm.
Question 4 of 5
When a client states that he is allergic to amoxicillin (Ampicillin) even though his medication administration record and armband do not indicate medication allergies, the nurse should:
Correct Answer: B
Rationale: Withholding the medication is the safest action until the allergy can be verified to prevent an allergic reaction.
Question 5 of 5
A client with chronic obstructive pulmonary disease is bedridden at home and gets little exercise. The nurse should assess the client for which of the following?
Correct Answer: B
Rationale: Prolonged immobility in COPD increases calcium excretion due to bone resorption, risking osteoporosis. The other options are not directly related to immobility.