NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 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.
Question 2 of 5
Which of the following impacts on the client's preferences in terms of hygiene routines and practices?
Correct Answer: A
Rationale: Culture significantly influences hygiene preferences, as beliefs and practices vary widely across cultural groups.
Question 3 of 5
What is the primary goal of nursing care during the emergent phase after a burn injury?
Correct Answer: A
Rationale: Replacing lost fluids is the primary goal in the emergent phase to prevent hypovolemic shock due to fluid loss from burns.
Question 4 of 5
A client has been hospitalized with heart failure. He is receiving digoxin (Lanoxin) and furosemide (Lasix) intravenously. He tells the nurse that he hears a continuous ringing in his ears and that he has never had this problem before. What is the appropriate action for the nurse to take at this time?
Correct Answer: A
Rationale: Ringing in the ears (tinnitus) is a sign of digoxin toxicity, requiring immediate checking of digoxin levels. Aspirin is less likely to cause this, and discontinuing furosemide or delaying action is inappropriate.
Question 5 of 5
A client with antisocial personality disorder tells the nurse, 'I punched the guy out because he deserved it and then the cops arrested me.' Which of the following responses would be most helpful to the client?
Correct Answer: B
Rationale: Explaining consequences (legal trouble) helps the client understand the impact of their actions, aligning with therapeutic communication for antisocial personality disorder.