NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
During your system specific assessment of your client's peripheral pulses, you note that the client's posterior tibia pulse is weak and thready. You would document this finding as:
Correct Answer: C
Rationale: A weak and thready pulse is documented as 1+ on a 0-4+ scale, indicating diminished pulse strength.
Question 2 of 5
Which action is included in the accurate procedure for administering heparin sodium subcutaneously?
Correct Answer: D
Rationale: Aspiration before administration of heparin sodium, an anticoagulant, should be avoided. Heparin administered by the subcutaneous route does not require an infusion device. The injection site is above the iliac crest or in the abdominal fat layer. It is injected at least 2 inches from the umbilicus. After administration, the needle is withdrawn, pressure is applied to the injection site, but the site is not massaged. Injection sites are rotated.
Question 3 of 5
A nurse is preparing to administer 500 mL of an I.V. solution to a child over 12 hours via tubing that delivers microdrips at 60 gtt/mL. At what rate should the nurse infuse the solution?
Correct Answer: A
Rationale: Calculate: 500 mL over 12 hours = 41.67 mL/hour. For microdrip (60 gtt/mL), 41.67 mL/hour ×60 gtt/mL = 2500 gtt/hour ÷ 60 minutes = 41.67 gtt/minute, rounded to 42 gtt/minute.
Question 4 of 5
When a breast-feeding mother reports experiencing nipple soreness, the nurse provides teaching regarding measures to relieve the soreness. Which statement by the mother indicates an understanding of the teaching?
Correct Answer: D
Rationale: Comfort measures for nipple soreness include positioning the infant with the ear, shoulder, and hip in straight alignment and with the infant's stomach against the mother's. Additional measures include rotating breastfeeding positions, breaking suction with the little finger, nursing frequently, beginning feeding on the less sore nipple, not allowing the infant to chew on the nipple or to sleep holding the nipple in the mouth, and applying tea bags soaked in warm water to the nipple. The remaining options are incorrect statements.
Question 5 of 5
Which of these skills is most closely related to successfully meeting the established priority needs of a group of clients?
Correct Answer: A
Rationale: Time management skills are critical for prioritizing and addressing the needs of multiple clients efficiently, ensuring that high-priority tasks are completed in a timely manner.