NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
The nurse is assessing a client with irreversible shock. The nurse should document which of the following?
Correct Answer: B
Rationale: Irreversible shock is characterized by circulatory collapse, with failure of vital organs due to inadequate perfusion, a critical finding to document.
Question 2 of 5
A client with a history of migraine headaches is prescribed sumatriptan (Imitrex). The nurse should instruct the client to:
Correct Answer: A
Rationale: Sumatriptan is most effective when taken at the onset of a migraine to abort the attack.
Question 3 of 5
A client has a history of syphilis infection. The nurse interprets that the client has been re-infected when which characteristic is noted in a penile lesion?
Correct Answer: C
Rationale: The characteristic lesion of syphilis is painless and indurated. The lesion is referred to as a chancre. Scabies is characterized by erythematous, papular eruptions. Genital warts are characterized by cauliflower-like growths, or growths that are soft and fleshy. Genital herpes is accompanied by the presence of one or more vesicles that then rupture and heal.
Question 4 of 5
A client with a new diagnosis of hypothyroidism is prescribed levothyroxine. What should the nurse include in the teaching plan?
Correct Answer: C
Rationale: Palpitations or chest pain may indicate overmedication or cardiac effects, requiring prompt reporting to adjust the levothyroxine dose.
Question 5 of 5
A client on a psychiatric care unit approaches the nurse and complains of muscle spasms in his neck, stiffness in other muscles, and that his eyes are rolling upward. The client had two p.r.n. doses of haloperidol (Haldol) in the last 6 hours. Of the drugs that have been ordered for the client as needed (see chart), the nurse should administer:
Correct Answer: D
Rationale: Dystonic adverse effects of haloperidol, especially oculogyric crises, are painful and frightening. I.M. benztropine is the fastest and most effective drug for managing dystonia. Lorazepam is an antianxiety medication and is not effective for treatment of dystonia. Although amantadine and diphenhydramine can be used for extrapyramidal symptoms, oral medications do not work as quickly, and amantadine may worsen psychotic symptoms.