NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
When a breast-feeding mother reports experiencing nipple soreness, the nurse provides teaching regarding measures to relieve the soreness. Which statement by the mother indicates an understanding of the teaching?
Correct Answer: D
Rationale: Comfort measures for nipple soreness include positioning the infant with the ear, shoulder, and hip in straight alignment and with the infant's stomach against the mother's. Additional measures include rotating breastfeeding positions, breaking suction with the little finger, nursing frequently, beginning feeding on the less sore nipple, not allowing the infant to chew on the nipple or to sleep holding the nipple in the mouth, and applying tea bags soaked in warm water to the nipple. The remaining options are incorrect statements.
Question 2 of 5
A client with a history of schizophrenia is prescribed clozapine (Clozaril). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Clozapine can cause agranulocytosis, requiring regular white blood cell monitoring.
Question 3 of 5
The nurse is teaching a client with hypertension about dietary modifications. Which statement by the client indicates understanding of the teaching?
Correct Answer: B
Rationale: Limiting sodium to 2,300 mg per day or less helps manage hypertension by reducing fluid retention and blood pressure.
Question 4 of 5
A client is reporting skin irritation from the edges of a cast that was applied the previous day. The nurse notes that the skin is pink and irritated. Which corrective action should the nurse take?
Correct Answer: A
Rationale: The nurse should petal the edges of the cast with tape to minimize skin irritation. Massaging the skin will not help the problem. Powder should not be shaken under the cast because it could clump, become moist, and cause skin breakdown. A hair dryer is used on a cool low setting if a nonplaster cast becomes wet or if the client's skin itches under a cast.
Question 5 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.