NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
The nurse is to administer a bolus starting dose of heparin to a child who is taking penicillin. What should the nurse do? Select all that apply.
Correct Answer: A,C,D
Rationale: Verifying the dose, administering a maintenance infusion, and monitoring PTT are standard for heparin therapy. Heparin's onset is immediate for I.V. but not a primary concern. Penicillin does not need discontinuation.
Question 2 of 5
A client undergoes cystoscopy with bladder biopsy. After the procedure, which assessment is most appropriate for the nurse to make?
Correct Answer: B
Rationale: Assessing for excessive bleeding post-cystoscopy with biopsy is critical due to the risk of hemorrhage. A Foley catheter may not be present, and culture is less urgent.
Question 3 of 5
A nurse is preparing to administer 500 mL of an I.V. solution to a child over 12 hours via tubing that delivers microdrips at 60 gtt/mL. At what rate should the nurse infuse the solution?
Correct Answer: A
Rationale: Calculate: 500 mL over 12 hours = 41.67 mL/hour. For microdrip (60 gtt/mL), 41.67 mL/hour ×60 gtt/mL = 2500 gtt/hour ÷ 60 minutes = 41.67 gtt/minute, rounded to 42 gtt/minute.
Question 4 of 5
A client with rheumatoid arthritis is prescribed methotrexate. Which laboratory value should the nurse monitor?
Correct Answer: A
Rationale: Methotrexate can cause hepatotoxicity, so monitoring liver function tests is essential.
Question 5 of 5
Which sound should you expect to hear when you percuss the liver during a complete physical assessment?
Correct Answer: D
Rationale: The liver, a solid organ, produces a dull sound when percussed, as opposed to the tympanic sound of air-filled structures or the resonant sound of lung tissue.