NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
The nurse is preparing to implement emergency care measures for the client who has just demonstrated signs and symptoms of a pulmonary embolism. Which primary health care provider prescription should the nurse implement first?
Correct Answer: A
Rationale: The client needs oxygen immediately because of hypoxemia, which is most often accompanied by respiratory distress and cyanosis. The client should also have an IV line for the administration of emergency medications such as morphine sulfate. An ECG is useful in determining the presence of possible right ventricular hypertrophy. All of the interventions listed are appropriate, but the client needs the oxygen first.
Question 2 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.
Question 3 of 5
A client had a positive Papanicolaou smear and underwent cryosurgery with laser therapy. What information should the nurse provide the client as a part of discharge teaching?
Correct Answer: C
Rationale: Cryosurgery is a procedure that involves freezing cervical tissues. Vaginal discharge should be clear and watery after the procedure. There is mild pain after the procedure, but opioid analgesics would not be required. Tub and sitz baths are avoided while the area is healing, which takes about 10 weeks. The client will begin to slough off dead cell debris, which may be odorous. This resolves within approximately 8 weeks.
Question 4 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 After administration, the needle is withdrawn, pressure is applied to the injection site, but the site is not massaged.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.
Question 5 of 5
The nurse is assessing a client with irreversible shock. The nurse should document which of the following?
Correct Answer: B
Rationale: Irreversible shock is characterized by circulatory collapse, with failure of vital organs due to inadequate perfusion, a critical finding to document.