NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is being treated with an intravenous (IV) bolus of lidocaine hydrochloride. What should the nurse monitor when considering the actions and the effects of this medication?
Correct Answer: D
Rationale: Lidocaine hydrochloride is an antidysrhythmic medication used to treat ventricular dysrhythmias. It can cause hypotension as a side effect, so monitoring blood pressure is critical to assess for adverse effects and ensure client safety. Urinary pH, radial pulse, and temperature are not directly related to the primary actions or adverse effects of lidocaine.
Question 2 of 5
When a breast-feeding mother reports experiencing nipple soreness, the nurse provides teaching regarding measures to relieve the soreness. Which statement by the mother indicates an understanding of the teaching?
Correct Answer: D
Rationale: Comfort measures for nipple soreness include positioning the infant with the ear, shoulder, and hip in straight alignment and with the infant's stomach against the mother's. Additional measures include rotating breastfeeding positions, breaking suction with the little finger, nursing frequently, beginning feeding on the less sore nipple, not allowing the infant to chew on the nipple or to sleep holding the nipple in the mouth, and applying tea bags soaked in warm water to the nipple. The remaining options are incorrect statements.
Question 3 of 5
A client has received electroconvulsive therapy (ECT). What intervention should the nurse perform first in the posttreatment area and upon the client's awakening?
Correct Answer: B
Rationale: The nurse should first monitor vital signs, orient the client, and review with the client that he or she just received an ECT treatment. The posttreatment area should include accessibility to the anesthesia staff, oxygen, suction, pulse oximeter, vital sign monitoring, and emergency equipment. The nursing interventions outlined in the remaining options will follow accordingly.
Question 4 of 5
An obese diabetic client complains of bilateral leg aching. His physician has referred him to cardiac rehabilitation to start an exercise program. Which of the following activities is most helpful for the client?
Correct Answer: A
Rationale: Stationary cycling is low-impact, suitable for an obese diabetic client, minimizing joint stress while improving cardiovascular health.
Question 5 of 5
Which action is included in the accurate procedure for administering heparin sodium subcutaneously?
Correct Answer: D
Rationale: Aspiration before administration of heparin sodium, an anticoagulant, should be avoided. Heparin administered by the subcutaneous route does not require an infusion device. The injection site is above the iliac crest or in the abdominal fat layer. It is injected at least 2 inches from the umbilicus. After administration, the needle is withdrawn, pressure is applied to the injection site, but the site is not massaged. Injection sites are rotated.