NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 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 2 of 5
A nurse at the outpatient clinic receives a lithium level report of 1.0 mEq/L for a client who has been taking lithium for 2 months. The nurse should interpret this level to indicate which of the following?
Correct Answer: D
Rationale: A lithium level of 1.0 mEq/L is within the therapeutic range (0.6–1.2 mEq/L) for maintenance therapy. Levels below this are subtherapeutic, and higher levels indicate toxicity.
Question 3 of 5
A client with a history of deep vein thrombosis is prescribed enoxaparin (Lovenox). Which laboratory value does not require routine monitoring?
Correct Answer: B
Rationale: Enoxaparin, a low-molecular-weight heparin, does not require routine PT monitoring, unlike warfarin, as it primarily affects anti-factor Xa activity.
Question 4 of 5
A client tells the nurse that he is going to harm his brother-in-law, who called the police on him for threatening to hurt his ex-wife. The nurse should notify which of the following persons? Select all that apply.
Correct Answer: C,D
Rationale: The nurse has a duty to warn the intended victim (brother-in-law) and notify the police due to the credible threat of harm. Notifying administrators or social services may be secondary, and the ex-wife is not the current target.
Question 5 of 5
The nurse is conducting a counseling session with a client experiencing post traumatic stress disorder (PTSD) using a 2-way video telehealth system from the hospital to the client's home, which is 2 hours away from the nearest mental health facility. Which of the following are expected outcomes of using telehealth as a venue to provide health care to this client? Select all that apply. The client will:
Correct Answer: A,B,D
Rationale: Telehealth reduces travel time, minimizes triggers associated with visiting facilities, and provides access to mental health care, but it does not inherently shorten recovery time or provide group support unless specifically designed.