NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
The nurse is teaching a client with hypertension about dietary modifications. Which statement by the client indicates understanding of the teaching?
Correct Answer: B
Rationale: Limiting sodium to 2,300 mg per day or less helps manage hypertension by reducing fluid retention and blood pressure.
Question 2 of 5
A client with a history of chronic kidney disease is admitted with hyperkalemia. The nurse should prioritize which of the following interventions?
Correct Answer: D
Rationale: Monitoring for dysrhythmias is the priority, as hyperkalemia can cause life-threatening cardiac arrhythmias.
Question 3 of 5
A client with a history of chronic obstructive pulmonary disease (COPD) is prescribed tiotropium (Spiriva). The nurse should instruct the client to:
Correct Answer: B
Rationale: Rinsing the mouth after tiotropium inhalation prevents oral thrush.
Question 4 of 5
A client has started taking amiodarone (Cordarone). The nurse should inform the client that periodic laboratory tests will be done to monitor the client's:
Correct Answer: B
Rationale: Amiodarone can cause hepatotoxicity, so periodic monitoring of liver enzymes is necessary to detect potential liver damage.
Question 5 of 5
The nurse is assigned to care for a client with a chest tube attached to closed chest drainage. Which assessment data should the nurse identify as an indicator that the client's lung has completely expanded?
Correct Answer: C
Rationale: When the lung has completely expanded, there is no longer air in the pleural space causing fluctuations in the water-seal chamber. Thus, an indication that a chest tube is ready for removal is when fluctuations in the water-seal chamber cease. Although air is known to be an irritant to pleural tissue, cessation of pleuritic pain does not indicate that the lung is expanded. The chest tube acts as an irritant and therefore contributes to pain. Adequate oxygen saturation does not imply that the lung has fully reexpanded. Use or nonuse of suction in the chest drainage system is not necessarily governed by the degree of lung expansion. Suction is indicated when gravity is not sufficient to drain air and pleural fluid or if the client has a poor respiratory effort and cough.