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
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 3 of 5
The nurse walks into the room of a client who has a 'do not resuscitate' order and finds the client without a pulse, respirations, or blood pressure. What is the most appropriate action?
Correct Answer: D
Rationale: For a DNR client, no resuscitation is performed. The nurse should respectfully leave the room after ensuring privacy, notifying the team as needed for post-mortem care.
Question 4 of 5
Which statement about environmental safety is accurate?
Correct Answer: D
Rationale: Advising clients to have an ABC fire extinguisher is accurate, as it is versatile for multiple fire types. Opening windows may worsen a fire, aiming the extinguisher follows pulling the pin, and rapid lifting risks injury.
Question 5 of 5
The nurse is caring for a client who is being treated with an intravenous (IV) bolus of lidocaine hydrochloride. What should the nurse monitor when considering the actions and the effects of this medication?
Correct Answer: D
Rationale: Lidocaine hydrochloride is an antidysrhythmic medication used to treat ventricular dysrhythmias. It can cause hypotension as a side effect, so monitoring blood pressure is critical to assess for adverse effects and ensure client safety. Urinary pH, radial pulse, and temperature are not directly related to the primary actions or adverse effects of lidocaine.