NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
What is the primary goal of nursing care during the emergent phase after a burn injury?
Correct Answer: A
Rationale: Replacing lost fluids is the primary goal in the emergent phase to prevent hypovolemic shock due to fluid loss from burns.
Question 2 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.
Question 3 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 4 of 5
A 6-year-old child is admitted with suspected appendicitis. Which symptom should the nurse prioritize when assessing this child?
Correct Answer: C
Rationale: Rebound tenderness in the right lower quadrant is a hallmark sign of appendicitis, indicating peritoneal irritation and requiring urgent surgical evaluation.
Question 5 of 5
A client with a history of type 2 diabetes mellitus is prescribed metformin (Glucophage). The nurse should instruct the client to report which of the following side effects immediately?
Correct Answer: C
Rationale: Lactic acidosis is a rare but serious side effect of metformin, requiring immediate reporting of symptoms like muscle pain or weakness.