NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 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 2 of 5
The nurse makes a home visit to a primiparous client and her neonate at 1 week after a vaginal delivery. Which of the following findings should be reported to the physician?
Correct Answer: D
Rationale: Neonatal central cyanosis indicates possible respiratory or cardiac issues and requires immediate reporting. The other findings are normal at 1 week postpartum.
Question 3 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 4 of 5
A client with a paranoid personality disorder sees some clients laughing during a group activity and asks the nurse, 'Why are they laughing at me? I bet they're making fun of me.' Which of the following responses by the nurse is most appropriate?
Correct Answer: D
Rationale: Providing a factual explanation that the laughter is due to a joke addresses the client's paranoia directly and reassuringly, reducing misinterpretation. Other responses dismiss or minimize the client's feelings.
Question 5 of 5
A client with a history of bipolar disorder is prescribed carbamazepine (Tegretol). The nurse should monitor the client for which of the following side effects?
Correct Answer: B
Rationale: Carbamazepine can cause agranulocytosis, requiring regular monitoring of white blood cell counts.