NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
Which manifestations associated with thyroid storm indicate the need for immediate nursing intervention?
Correct Answer: C
Rationale: The excessive amounts of thyroid hormone cause a rapid increase in the metabolic rate, thereby causing the manifestations of thyroid storm such as fever, tachycardia, and hypertension. When these signs present themselves, the nurse must take quick action to prevent deterioration of the client's health because death can ensue. Priority interventions include maintaining a patent airway and stabilizing the hemodynamic status. The remaining options do not indicate the need for immediate nursing intervention nor are they associated with thyroid storm.
Question 2 of 5
The nurse is assessing a client with irreversible shock. The nurse should document which of the following?
Correct Answer: B
Rationale: Irreversible shock is characterized by circulatory collapse, with failure of vital organs due to inadequate perfusion, a critical finding to document.
Question 3 of 5
A client with a history of chronic lymphocytic leukemia is admitted with fatigue and pallor. Which laboratory value should the nurse monitor?
Correct Answer: D
Rationale: Chronic lymphocytic leukemia can cause anemia (low hemoglobin), infection risk (abnormal WBCs), and bleeding risk (low platelets), requiring monitoring of all values.
Question 4 of 5
A client with a history of breast cancer is prescribed letrozole (Femara). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Letrozole, an aromatase inhibitor, can cause bone loss, increasing osteoporosis risk.
Question 5 of 5
Sertraline is prescribed for a client in the treatment of depression. Before administering the medication, the nurse reviews the client's record and consults with the primary health care provider when which finding is noted?
Correct Answer: A
Rationale: Sertraline is a serotonin reuptake inhibitor. Serious potentially fatal reactions may occur if sertraline is administered concurrently with a monoamine oxidase inhibitor (MAOI). Phenelzine sulfate is an MAOI. MAOIs should be stopped at least 14 days before sertraline therapy. Sertraline should also be stopped at least 14 days before MAOI therapy. The remaining options are not concerns associated with the administration of this medication.