NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
You are caring for a hospice client who is at the end of life. Based on this client's signs and symptoms, the client is comatose, dehydrated, free of pain, constipated, without distress and expected to die in a day or two. Which of the following is an appropriate client outcome or an appropriate intervention for this client?
Correct Answer: B
Rationale: Given the client's comatose state and imminent death, the priority is to maintain comfort. Ensuring the client remains free of pain and distress is the most appropriate outcome, as aggressive interventions like enemas or antiemetics are less relevant in this context.
Question 2 of 5
The nurse is caring for a client who is being treated with an intravenous (IV) bolus of lidocaine hydrochloride. What should the nurse monitor when considering the actions and the effects of this medication?
Correct Answer: D
Rationale: Lidocaine hydrochloride is an antidysrhythmic medication used to treat ventricular dysrhythmias. It can cause hypotension as a side effect, so monitoring blood pressure is critical to assess for adverse effects and ensure client safety. Urinary pH, radial pulse, and temperature are not directly related to the primary actions or adverse effects of lidocaine.
Question 3 of 5
The nurse is caring for a client who has just received a diagnosis of terminal cancer. The client says, 'I don't want to tell my family yet.' Which of the following responses by the nurse is most appropriate?
Correct Answer: B
Rationale: Respecting the client's autonomy while offering support is the most appropriate response, honoring their decision about disclosure.
Question 4 of 5
A client with cirrhosis is admitted with ascites. The nurse should monitor the client for which of the following complications?
Correct Answer: A
Rationale: Ascites can cause diaphragmatic compression, leading to respiratory distress, which requires monitoring.
Question 5 of 5
The nurse is evaluating the client's potential for development of a pressure sore. Which of the following individual characteristics would be the best indicator of risk for the client's developing a pressure sore?
Correct Answer: C
Rationale: Immobility is the primary risk factor for pressure sores, as it leads to prolonged pressure on tissues.