NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 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 2 of 5
A client with a history of cirrhosis is admitted with esophageal varices. The nurse should monitor the client for which of the following complications?
Correct Answer: A, B
Rationale: Esophageal varices can rupture, causing hematemesis and hypotension.
Question 3 of 5
A client with a diagnosis of bipolar disorder is prescribed lithium. The nurse should monitor the client for which of the following early signs of toxicity?
Correct Answer: A
Rationale: Tremors are an early sign of lithium toxicity, requiring prompt monitoring and potential dose adjustment.
Question 4 of 5
During the health history interview, which of the following strategies is the most effective for the nurse to use to help clients feel that they have an active role in their health care?
Correct Answer: C
Rationale: Engaging clients by asking for their description of events and views on past medical care promotes active participation, fosters trust, and ensures the nurse understands the client's perspective, which is critical for patient-centered care.
Question 5 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 After administration, the needle is withdrawn, pressure is applied to the injection site, but the site is not massaged.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.