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
A client with a hip fracture is scheduled for surgery. Which preoperative teaching should the nurse include?
Correct Answer: C
Rationale: Incentive spirometry prevents postoperative pulmonary complications like atelectasis, critical for a client with limited mobility post-hip surgery.
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
The nurse is caring for a client who has just undergone a liver biopsy. Which of the following interventions is most important in the immediate post-procedure period?
Correct Answer: A
Rationale: Keeping the client on the right side for 2 hours post-liver biopsy applies pressure to the site, reducing the risk of bleeding.
Question 5 of 5
The nurse is teaching a client with a new diagnosis of hypertension about the DASH diet. Which of the following foods should the nurse recommend?
Correct Answer: B
Rationale: Bananas are rich in potassium and part of the DASH diet, which promotes heart-healthy eating to manage hypertension.