NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
The nurse is conducting health assessments for school-age children. A characteristic behavior of a 7-year-old girl is that she:
Correct Answer: C
Rationale: At 7 years, children typically enjoy social interaction and team games, reflecting their developmental stage of cooperative play.
Question 2 of 5
A client with a diagnosis of bipolar disorder is prescribed lithium. The nurse should monitor the client for which of the following early signs of toxicity?
Correct Answer: A
Rationale: Tremors are an early sign of lithium toxicity, requiring prompt monitoring and potential dose adjustment.
Question 3 of 5
Which actions should the nurse implement to prevent ventilator-associated pneumonia (VAP) in the client who is intubated and on mechanical ventilation?
Correct Answer: A
Rationale: Because normal upper airway defenses are bypassed, clients who are intubated with mechanical ventilation are at risk for VAP. Prevention includes effective hand washing before and after suctioning, when touching ventilator equipment, and when in contact with respiratory secretions.
To prevent aspiration of colonized secretions from the oral cavity, the client will need more frequent oral cavity suctioning and at least 30 degrees head of the bed elevation. The more frequently the circuit is broken, the greater the risk for pathogen entry.
Question 4 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.
Question 5 of 5
A 6-year-old child is admitted with suspected appendicitis. Which symptom should the nurse prioritize when assessing this child?
Correct Answer: C
Rationale: Rebound tenderness in the right lower quadrant is a hallmark sign of appendicitis, indicating peritoneal irritation and requiring urgent surgical evaluation.