NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 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 After administration, the needle is withdrawn, pressure is applied to the injection site, but the site is not massaged.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.
Question 2 of 5
A 4-year-old child is admitted with dehydration due to gastroenteritis. Which assessment finding indicates severe dehydration?
Correct Answer: C
Rationale: Sunken fontanelles in a young child are a sign of severe dehydration, indicating significant fluid loss requiring urgent rehydration.
Question 3 of 5
A client on a psychiatric care unit approaches the nurse and complains of muscle spasms in his neck, stiffness in other muscles, and that his eyes are rolling upward. The client had two p.r.n. doses of haloperidol (Haldol) in the last 6 hours. Of the drugs that have been ordered for the client as needed (see chart), the nurse should administer:
Correct Answer: D
Rationale: Dystonic adverse effects of haloperidol, especially oculogyric crises, are painful and frightening. I.M. benztropine is the fastest and most effective drug for managing dystonia. Lorazepam is an antianxiety medication and is not effective for treatment of dystonia. Although amantadine and diphenhydramine can be used for extrapyramidal symptoms, oral medications do not work as quickly, and amantadine may worsen psychotic symptoms.
Question 4 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 5 of 5
You are caring for a postoperative client who is complaining of abdominal distention and flatus. Which intervention would you most likely do for this client?
Correct Answer: C
Rationale: A return-flow enema is specifically used to relieve abdominal distention and flatus by introducing and then removing fluid to stimulate gas expulsion.