NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a client who has just received a diagnosis of terminal cancer. The client says, 'I don't want to tell my family yet.' Which of the following responses by the nurse is most appropriate?
Correct Answer: B
Rationale: Respecting the client's autonomy while offering support is the most appropriate response, honoring their decision about disclosure.
Question 2 of 5
A client with a history of chronic obstructive pulmonary disease (COPD) is prescribed tiotropium (Spiriva). The nurse should instruct the client to:
Correct Answer: B
Rationale: Rinsing the mouth after tiotropium inhalation prevents oral thrush.
Question 3 of 5
A client has a total hip replacement. Which of the following client statements indicates a need for further teaching before discharge?
Correct Answer: D
Rationale: Tub baths are contraindicated post-hip replacement due to the risk of hip flexion beyond 90 degrees, indicating a need for further teaching.
Question 4 of 5
A client with a history of deep vein thrombosis is prescribed enoxaparin (Lovenox). Which laboratory value does not require routine monitoring?
Correct Answer: B
Rationale: Enoxaparin, a low-molecular-weight heparin, does not require routine PT monitoring, unlike warfarin, as it primarily affects anti-factor Xa activity.
Question 5 of 5
The nurse is evaluating the client's potential for development of a pressure sore. Which of the following individual characteristics would be the best indicator of risk for the client's developing a pressure sore?
Correct Answer: C
Rationale: Immobility is the primary risk factor for pressure sores, as it leads to prolonged pressure on tissues.