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 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 3 of 5
The nurse is teaching a client with a new diagnosis of gout about dietary management. Which of the following foods should the client include?
Correct Answer: A
Rationale: Cherries reduce uric acid levels and inflammation in gout.
Question 4 of 5
A client with a paranoid personality disorder sees some clients laughing during a group activity and asks the nurse, 'Why are they laughing at me? I bet they're making fun of me.' Which of the following responses by the nurse is most appropriate?
Correct Answer: D
Rationale: Providing a factual explanation that the laughter is due to a joke addresses the client's paranoia directly and reassuringly, reducing misinterpretation. Other responses dismiss or minimize the client's feelings.
Question 5 of 5
A client who had undergone an abdominal hysterectomy is in the recovery room. The surgeon has ordered a 250-mL bolus of normal saline over 1 hour to replace blood loss. The I.V. solution infusing in the client was 1,000 mL normal saline with 40 mEq of potassium chloride at 100 mL/hour. The nurse should: Select all that apply.
Correct Answer: C,E
Rationale: A separate 250-mL bag via Y-connection and infusion pump ensures accurate delivery of the bolus without altering the primary infusion.