NCLEX-RN
NCLEX RN SATA Questions Questions
Extract:
Question 1 of 5
You have loosely applied a bed sheet around your client's waist to prevent a fall from the chair. What have you done?
Correct Answer: D
Rationale: Applying a bed sheet around the client's waist without a proper restraint order constitutes an illegal restraint, which is a crime , as it restricts freedom without proper authorization or consent.
Question 2 of 5
A client who had undergone an abdominal hysterectomy is in the recovery room. The surgeon has ordered a 250-mL bolus of normal saline over 1 hour to replace blood loss. The I.V. solution infusing in the client was 1,000 mL normal saline with 40 mEq of potassium chloride at 100 mL/hour. The nurse should: Select all that apply.
Correct Answer: C,E
Rationale: A separate 250-mL bag via Y-connection and infusion pump ensures accurate delivery of the bolus without altering the primary infusion.
Question 3 of 5
What is the primary goal of nursing care during the emergent phase after a burn injury?
Correct Answer: A
Rationale: Replacing lost fluids is the primary goal in the emergent phase to prevent hypovolemic shock due to fluid loss from burns.
Question 4 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 After administration, the needle is withdrawn, pressure is applied to the injection site, but the site is not massaged.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 5 of 5
A client with a history of bipolar disorder is prescribed carbamazepine (Tegretol). The nurse should monitor the client for which of the following side effects?
Correct Answer: B
Rationale: Carbamazepine can cause agranulocytosis, requiring regular monitoring of white blood cell counts.