NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a client who has just undergone a liver biopsy. Which of the following interventions is most important in the immediate post-procedure period?
Correct Answer: A
Rationale: Keeping the client on the right side for 2 hours post-liver biopsy applies pressure to the site, reducing the risk of bleeding.
Question 2 of 5
A client is reporting skin irritation from the edges of a cast that was applied the previous day. The nurse notes that the skin is pink and irritated. Which corrective action should the nurse take?
Correct Answer: A
Rationale: The nurse should petal the edges of the cast with tape to minimize skin irritation. Massaging the skin will not help the problem. Powder should not be shaken under the cast because it could clump, become moist, and cause skin breakdown. A hair dryer is used on a cool low setting if a nonplaster cast becomes wet or if the client's skin itches under a cast.
Question 3 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.
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 family member asks to take the client, who is on aneurysm precautions, to the unit lounge for 'just a few minutes.' Which concepts should the nurse use when explaining why the client must remain in the room?
Correct Answer: C
Rationale: Subarachnoid precautions (or aneurysm precautions) are intended to minimize environmental stimuli, which could increase intracranial pressure and trigger bleeding or rupture of the aneurysm. The aneurysm will not heal more rapidly with reduced stimuli. The client does not need isolation to 'cope' with photosensitivity (although photosensitivity may be a problem). No data indicate that the client has disorganization of thoughts and feelings.