NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
The nurse is delivering care to a client who is diagnosed with toxic shock syndrome (TSS). Which complication of this syndrome should the nurse monitor the client for?
Correct Answer: D
Rationale: TSS is caused by infection and is often associated with tampon use. DIC is a complication of TSS. The nurse monitors the client for signs of this complication, and notifies the primary health care provider promptly if signs and symptoms are noted. The other options are not complications of TSS.
Question 2 of 5
Which manifestations associated with thyroid storm indicate the need for immediate nursing intervention?
Correct Answer: C
Rationale: The excessive amounts of thyroid hormone cause a rapid increase in the metabolic rate, thereby causing the manifestations of thyroid storm such as fever, tachycardia, and hypertension. When these signs present themselves, the nurse must take quick action to prevent deterioration of the client's health because death can ensue. Priority interventions include maintaining a patent airway and stabilizing the hemodynamic status. The remaining options do not indicate the need for immediate nursing intervention nor are they associated with thyroid storm.
Question 3 of 5
To prevent development of peripheral neuropathies associated with isoniazid administration, the nurse should teach the client to:
Correct Answer: D
Rationale: Isoniazid can deplete vitamin B6, leading to neuropathy; supplementation prevents this side effect.
Question 4 of 5
Your client has a doctor's order for the antihistamine medication diphenhydramine for sleep. What should you do?
Correct Answer: D
Rationale: Diphenhydramine (Benadryl) is commonly used off-label for sleep due to its sedative effects, making it an appropriate choice if ordered for this purpose.
Question 5 of 5
The nurse should advise which of the following clients who is taking lithium to consult with the physician regarding a potential adjustment in lithium dosage?
Correct Answer: D
Rationale: Increased physical activity, such as tennis training, can lead to dehydration or electrolyte imbalances, which may affect lithium levels and increase toxicity risk, necessitating a dosage adjustment.