NCLEX RN· Full Length · NCLEX RN SATA Questions
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Showing all 10 practice questions with expert explanatory rationales.
The nurse is assessing a client with irreversible shock. The nurse should document which of the following?
Expert Explanatory Rationale
Correct Answer: Circulatory collapse.
Irreversible shock is characterized by circulatory collapse, with failure of vital organs due to inadequate perfusion, a critical finding to document.
Chemical cardioversion is prescribed for the client diagnosed with atrial fibrillation. The nurse who is assisting in preparing the client should expect that which medication specific for chemical cardioversion would be prescribed?
Expert Explanatory Rationale
Correct Answer: Amiodarone
Amiodarone is an antidysrhythmic that is useful in restoring normal sinus rhythm for the client experiencing atrial fibrillation. Lidocaine is used for control of ventricular dysrhythmias. Both nifedipine and nitroglycerin are vasodilators and are prescribed for the restoration of a normal sinus rhythm.
The nurse is caring for a client with a suspected stroke. Which assessment should the nurse perform first?
Expert Explanatory Rationale
Correct Answer: Evaluate speech and motor function
Evaluating speech and motor function first helps confirm stroke symptoms using tools like the FAST scale, guiding urgent intervention.
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?
Expert Explanatory Rationale
Correct Answer: Agranulocytosis.
Carbamazepine can cause agranulocytosis, requiring regular monitoring of white blood cell counts.
A 72-year-old client is referred for counseling. During the initial nursing assessment, the client denies the need for counseling. The nurse would agree with the client if she made which of the following comments?
Expert Explanatory Rationale
Correct Answer: Since I've gotten over the death of my husband, I've had more energy and been more active than before he died.'
Increased energy and activity post-grief suggest the client is coping well, supporting her denial of needing counseling.
A client is admitted to the hospital after sustaining a fall from a roof. The client has multiple lacerations and a right leg fracture, which has been treated with a plaster cast. How should the nurse position the client's leg to promote optimal circulation?
Expert Explanatory Rationale
Correct Answer: Elevated on pillows continuously for 24 to 48 hours
A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and promote venous drainage. The other options are not part of standard positioning of the newly casted extremity.
A client is receiving total parenteral nutrition (TPN). The nurse notices that the bag of TPN solution has been infusing for 24 hours but has $300 \mathrm{~mL}$ of solution left. The nurse should:
Expert Explanatory Rationale
Correct Answer: Discontinue the current solution, change the tubing, and hang a new bag of TPN solution
TPN solutions should not hang for more than 24 hours due to infection risk. The nurse should discontinue the current bag, change the tubing, and hang a new bag. Continuing or altering the rate is unsafe.
While assisting the physician with an amniocentesis on a multigravid client at 38 weeks' gestation, the nurse observes that the fluid is very cloudy and thick. The nurse interprets this finding as indicating which of the following?
Expert Explanatory Rationale
Correct Answer: Fetal meconium staining.
Cloudy, thick amniotic fluid often indicates meconium staining, suggesting fetal distress, which requires further evaluation.
A 13-year-old client is dying of cancer and struggling with the emotional aspects of this. When providing care for this client, the nurse should incorporate the developmental tasks for this age. According to Erikson's developmental model, the child normally is expected to be working on which of the following psychosocial issues?
Expert Explanatory Rationale
Correct Answer: Identity vs. role confusion.
Adolescents (ages 12–18) focus on identity vs. role confusion, developing a sense of self and personal identity.
A client is prescribed diphenhydramine 1% as a topical agent for allergic dermatosis. The nurse evaluates that the medication is having the intended effect when the client reports relief of what complaint?
Expert Explanatory Rationale
Correct Answer: Urticaria
Diphenhydramine is an antihistamine medication that has many uses. When used as a topical agent on the skin, it reduces the symptoms of allergic reaction, such as itching or urticaria. It does not act to relieve pain, headache, or skin redness.
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