NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
The nurse assesses a client and notes puffy eyelids, swollen ankles, and crackles at both lung bases. The nurse understands that these clinical findings are most specifically associated with fluid excess in which of the following compartments?
Correct Answer: C
Rationale: These symptoms indicate fluid excess in the extracellular compartment, which includes interstitial spaces (edema) and intravascular spaces (contributing to lung crackles).
Question 2 of 5
On the first postpartum day, the nurse is caring for a primiparous client who has recently emigrated from Japan to the United States and speaks only a little English. The nurse observes that the client has been bottle-feeding her neonate on occasion, but most of the neonatal care is being performed by the client's mother-in-law. Which of the following actions would be most appropriate?
Correct Answer: C
Rationale: Assessing whether the mother-in-law's involvement is a cultural practice respects the client's background and avoids misjudging normal family dynamics.
Question 3 of 5
Your client is experiencing general malaise. Which stage of infection is this client in?
Correct Answer: B
Rationale: General malaise is characteristic of the illness stage, where symptoms of the infection are most prominent.
Question 4 of 5
Carbamazepine is prescribed for the management of generalized tonic-clonic seizures. The nurse instructs the client to inform the primary health care provider if which sign/symptom occurs?
Correct Answer: C
Rationale: Drowsiness, dizziness, nausea, and vomiting are frequent side effects associated with the medication. Adverse reactions include blood dyscrasias. If the client develops a fever, sore throat, mouth ulcerations, unusual bleeding or bruising, or joint pain, this may be indicative of a blood dyscrasia, and the primary health care provider should be notified.
Question 5 of 5
The nurse is assessing the leg pain of a client who has just undergone right femoral-popliteal artery bypass grafting. Which question would be most useful in determining whether the client is experiencing graft occlusion?
Correct Answer: D
Rationale: The most frequent indication that a graft is occluding is the return of pain that is similar to that experienced preoperatively. Standard pain assessment techniques also include the items described in the remaining options, but these will not help differentiate current pain from preoperative pain.