NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
The nurse is assigned to care for a client with a chest tube attached to closed chest drainage. Which assessment data should the nurse identify as an indicator that the client's lung has completely expanded?
Correct Answer: C
Rationale: When the lung has completely expanded, there is no longer air in the pleural space causing fluctuations in the water-seal chamber. Thus, an indication that a chest tube is ready for removal is when fluctuations in the water-seal chamber cease. Although air is known to be an irritant to pleural tissue, cessation of pleuritic pain does not indicate that the lung is expanded. The chest tube acts as an irritant and therefore contributes to pain. Adequate oxygen saturation does not imply that the lung has fully reexpanded. Use or nonuse of suction in the chest drainage system is not necessarily governed by the degree of lung expansion. Suction is indicated when gravity is not sufficient to drain air and pleural fluid or if the client has a poor respiratory effort and cough.
Question 2 of 5
During the health history interview, which of the following strategies is the most effective for the nurse to use to help clients feel that they have an active role in their health care?
Correct Answer: C
Rationale: Engaging clients by asking for their description of events and views on past medical care promotes active participation, fosters trust, and ensures the nurse understands the client's perspective, which is critical for patient-centered care.
Question 3 of 5
A client with cirrhosis is admitted with ascites. The nurse should monitor the client for which of the following complications?
Correct Answer: A
Rationale: Ascites can cause diaphragmatic compression, leading to respiratory distress, which requires monitoring.
Question 4 of 5
A client with a diagnosis of breast cancer is prescribed letrozole (Femara). The nurse should instruct the client to report which of the following side effects immediately?
Correct Answer: B
Rationale: Bone pain may indicate bone loss or metastasis, a serious side effect of letrozole requiring immediate reporting.
Question 5 of 5
A client has massive bleeding from esophageal varices. In what order should the nurse and care team provide care for this client?
Order the Items
Source Container
Correct Answer: D, A, B, C
Rationale: The priority is to maintain a patent airway, control hemorrhaging, replace fluids, and then address anxiety to stabilize the client.