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
The nurse is caring for a client who is being treated with an intravenous (IV) bolus of lidocaine hydrochloride. What should the nurse monitor when considering the actions and the effects of this medication?
Correct Answer: D
Rationale: Lidocaine hydrochloride is an antidysrhythmic medication used to treat ventricular dysrhythmias. It can cause hypotension as a side effect, so monitoring blood pressure is critical to assess for adverse effects and ensure client safety. Urinary pH, radial pulse, and temperature are not directly related to the primary actions or adverse effects of lidocaine.
Question 3 of 5
The client received electroconvulsive therapy (ECT) an hour ago and tells the nurse that he has a headache. Which response by the nurse is best?
Correct Answer: B
Rationale: Offering acetaminophen addresses the client's complaint directly and safely, as headaches are a common side effect of ECT. Informing the client that headaches are common does not provide relief, and a nap or unclear commands are not appropriate responses.
Question 4 of 5
You have loosely applied a bed sheet around your client's waist to prevent a fall from the chair. What have you done?
Correct Answer: D
Rationale: Applying a bed sheet around the client's waist without a proper restraint order constitutes an illegal restraint, which is a crime , as it restricts freedom without proper authorization or consent.
Question 5 of 5
The nursing staff has safely and successfully secluded and restrained a client with acute mania who discussed the nurse and threw a chair against the wall in the community room. Which statement by the nurse is most helpful to the client at this time?
Correct Answer: B
Rationale: Explaining the reason for restraint (to ensure safety until behavior is managed) is therapeutic, clear, and nonjudgmental, helping the client understand the intervention.