NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
When a client states that he is allergic to amoxicillin (Ampicillin) even though his medication administration record and armband do not indicate medication allergies, the nurse should:
Correct Answer: B
Rationale: Withholding the medication is the safest action until the allergy can be verified to prevent an allergic reaction.
Question 2 of 5
During your system specific assessment of your client's peripheral pulses, you note that the client's posterior tibia pulse is weak and thready. You would document this finding as:
Correct Answer: C
Rationale: A weak and thready pulse is documented as 1+ on a 0-4+ scale, indicating diminished pulse strength.
Question 3 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 4 of 5
A client undergoes cystoscopy with bladder biopsy. After the procedure, which assessment is most appropriate for the nurse to make?
Correct Answer: B
Rationale: Assessing for excessive bleeding post-cystoscopy with biopsy is critical due to the risk of hemorrhage. A Foley catheter may not be present, and culture is less urgent.
Question 5 of 5
When a client states that he is allergic to amoxicillin (Ampicillin) even though his medication administration record and armband do not indicate medication allergies, the nurse should:
Correct Answer: B
Rationale: Withholding the medication is the safest action until the allergy can be verified to prevent an allergic reaction.