NCLEX SATA 1 4.

Acetone breath
1. A patient is admitted to the same day surgery unit 5. Elevated serum bicarbonate
for liver biopsy. Which of the following laboratory tests 9. When planning care for a client with ulcerative colitis
assesses coagulation? Select all that apply. who is experiencing symptoms, which client care
1. Partial thromboplastin time. activities can the nurse appropriately delegate to a
2. Prothrombin time. unlicensed assistant? Select all that apply.
3. Platelet count. 1. Assessing the client’s bowel sounds
4. Hemoglobin 2. Providing skin care following bowel movements
5. Complete Blood Count 3. Evaluating the client’s response to antidiarrheal
6. White Blood Cell Count medications
2. A patient is admitted to the hospital with suspected 4. Maintaining intake and output records
polycythemia vera. Which of the following symptoms is 5. Obtaining the client’s weight.
consistent with the diagnosis? Select all that apply. 10. Which of the following nursing diagnoses would be
1. Weight loss. appropriate for a client with heart failure? Select all
2. Increased clotting time. that apply.
3. Hypertension. 1. Ineffective tissue perfusion ​related to​ decreased peripheral
4. Headaches. blood flow secondary to decreased cardiac output.
3. The nurse is teaching the client how to use a 2. Activity intolerance ​related to​ increased cardiac output.
metered dose inhaler (MDI) to administer a 3. Decreased cardiac output ​related to​ structural and
Corticosteroid drug. Which of the following client functional changes.
actions indicates that he is using the MDI correctly? 4. Impaired gas exchange ​related to​ decreased sympathetic
Select all that apply. nervous system activity.
1. The inhaler is held upright. 11. When caring for a client with a central venous line,
2. Head is tilted down while inhaling the medication which of the following nursing actions should be
3. Client waits 5 minutes between puffs. implemented in the plan of care for chemotherapy
4. Mouth is rinsed with water following administration administration? Select all that apply.
5. Client lies supine for 15 minutes following administration. 1. Verify patency of the line by the presence of a blood return
4. The nurse is teaching a client with polycythemia vera at regular intervals.
about potential complications from this disease. Which 2. Inspect the insertion site for swelling, erythema, or
manifestations would the nurse include in the client’s drainage.
teaching plan? Select all that apply. 3. Administer a cytotoxic agent to keep the regimen on
1. Hearing loss schedule even if blood return is not present.
2. Visual disturbance 4. If unable to aspirate blood, reposition the client and
3. Headache encourage the client to cough.
4. Orthopnea 5. Contact the health care provider about verifying placement
5. Gout if the status is questionable.
6. Weight loss 12. A 20-year old college student has been brought to
5. Which of the following would be priority assessment the psychiatric hospital by her parents. Her admitting
data to gather from a client who has been diagnosed diagnosis is borderline personality disorder. When
with pneumonia? Select all that apply. talking with the parents, which information would the
1. Auscultation of breath sounds nurse expect to be included in the client’s history?
2. Auscultation of bowel sounds Select all that apply.
3. Presence of chest pain. 1. Impulsiveness
4. Presence of peripheral edema 2. Lability of mood
5. Color of nail beds 3. Ritualistic behavior
6. The nurse is teaching a client who has been 4. psychomotor retardation
diagnosed with TB how to avoid spreading the disease 5. Self-destructive behavior
to family members. Which statement(s) by the client 13. When assessing a client diagnosed with impulse
indicate(s) that he has understood the nurses control disorder, the nurse observes violent,
instructions? Select all that apply. aggressive, and assaultive behavior. Which of the
1. “I will need to dispose of my old clothing when I return following assessment data is the nurse also likely to
home.” find? Select all that apply.
2. “I should always cover my mouth and nose when 1. The client functions well in other areas of his life.
sneezing.” 2. The degree of aggressiveness is out of proportion to the
3. “It is important that I isolate myself from family when stressor.
possible.” 3. The violent behavior is most often justified by the stressor.
4. “I should use paper tissues to cough in and dispose of 4. The client has a history of parental alcoholism and chaotic,
them properly.” abusive family life.
5. “I can use regular plate and utensils whenever I eat.” 5. The client has no remorse about the inability to control his
7. The nurse is admitting a client with hypoglycemia. anger.
Identify the signs and symptoms the nurse should 14. Which of the following nursing interventions are
expect. Select all that apply. written correctly? (Select all that apply.)
1. Thirst 1. Apply continuous passive motion machine during day.
2. Palpitations 2. Perform neurovascular checks.
3. Diaphoresis 3. Elevate head of bed 30 degrees before meals.
4. Slurred speech 4. Change dressing once a shift.
5. Hyperventilation 15. The nurse is monitoring a client receiving
8. Which adaptations should the nurse caring for a peritoneal dialysis and nurse notes that a client’s
client with diabetic ketoacidosis expect the client to outflow is less than the inflow. Select actions that the
exhibit? Select all that apply: nurse should take.
1. Sweating 1. Place the client in good body alignment
2. Low PCO2 2. Check the level of the drainage bag
3. Retinopathy 3. Contact the physician
4. Check the peritoneal dialysis system for kinks
5. Reposition the client to his or her side.
16. The nurse is caring for a hospitalized client who has
chronic renal failure. Which of the following nursing
diagnoses are most appropriate for this client? Select
all that apply.
1. Excess Fluid Volume
2. Imbalanced Nutrition; Less than Body Requirements
3. Activity Intolerance
4. Impaired Gas Exchange
5. Pain.
17. The nurse is assessing a child diagnosed with a
brain tumor. Which of the following signs and
symptoms would the nurse expect the child to
demonstrate? Select all that apply.
1. Head tilt
2. Vomiting
3. Polydipsia
4. Lethargy
5. Increased appetite
6. Increased pulse
18. The nurse is caring for a client with a T5 complete
spinal cord injury. Upon assessment, the nurse notes
flushed skin, diaphoresis above the T5, and a blood
pressure of 162/96. The client reports a severe,
pounding headache. Which of the following nursing
interventions would be appropriate for this client?
Select all that apply.
1. Elevate the HOB to 90 degrees
2. Loosen constrictive clothing
3. Use a fan to reduce diaphoresis
4. Assess for bladder distention and bowel impaction
5. Administer antihypertensive medication
6. Place the client in a supine position with legs elevated
19. The nurse is evaluating the discharge teaching for a
client who has an ileal conduit. Which of the following
statements indicates that the client has correctly
understood the teaching? Select all that apply.
1. “If I limit my fluid intake I will not have to empty my
ostomy pouch as often.”
2. “I can place an aspirin tablet in my pouch to decrease
odor.”
3. “I can usually keep my ostomy pouch on for 3 to 7 days
before changing it.”
4. “I must use a skin barrier to protect my skin from urine.”
5. “I should empty my ostomy pouch of urine when it is full.”
20. A nurse is assisting in performing an assessment on
a client who suspects that she is pregnant and is
checking the client for probable signs of
pregnancy. ​Select all​ probable signs of pregnancy.
1. Uterine enlargement
2. Fetal heart rate detected by nonelectric device
3. Outline of the fetus via radiography or ultrasound
4. Chadwick’s sign
5. Braxton Hicks contractions
6. Ballottement
21. A nurse is monitoring a pregnant client with
pregnancy induced hypertension who is at risk for
Preeclampsia. The nurse checks the client for which
specific signs of Preeclampsia (select all that apply)?
1. Elevated blood pressure
2. Negative urinary protein
3. Facial edema
4. Increased respirations
22. A nurse is caring for a pregnant client with severe
preeclampsia who is receiving IV magnesium sulfate.
Select ​all ​nursing interventions that apply in the care
for the client.
1. Monitor maternal vital signs every 2 hours
2. Notify the physician if respirations are less than 18 per
minute.
3. Monitor renal function and cardiac function closely
4. Keep calcium gluconate on hand in case of a magnesium
sulfate overdose
5. Monitor deep tendon reflexes hourly
6. Monitor I and O’s hourly
7. Notify the physician if urinary output is less than 30 ml per
hour.
23. When interpreting an ECG, the nurse would keep in
mind which of the following about the P wave? Select
all that apply.
1. Reflects electrical impulse beginning at the SA node
2. Indicated electrical impulse beginning at the AV node
3. Reflects atrial muscle depolarization
4. Identifies ventricular muscle depolarization
5. Has duration of normally 0.11 seconds or less.
24. When caring for a client with a central venous line,
which of the following nursing actions should be
implemented in the plan of care for chemotherapy
administration? Select all that apply.
1. Verify patency of the line by the presence of a blood return
at regular intervals.
2. Inspect the insertion site for swelling, erythema, or
drainage.
3. Administer a cytotoxic agent to keep the regimen on
schedule even if blood return is not present.
4. If unable to aspirate blood, reposition the client and
encourage the client to cough.
5. Contact the health care provider about verifying placement
if the status is questionable.
25. To assist an adult client to sleep better the nurse
recommends which of the following? (Select all that
apply.)
1. Drinking a glass of wine just before retiring to bed
2. Eating a large meal 1 hour before bedtime
3. Consuming a small glass of warm milk at bedtime
4. Performing mild exercises 30 minutes before going to bed
26. The nurse recognizes that a client is experiencing
insomnia when the client reports (select all that apply):
1. Extended time to fall asleep
2. Falling asleep at inappropriate times
3. Difficulty staying asleep
4. Feeling tired after a night’s sleep
27. The nurse teaches the mother of a newborn that in
order to prevent sudden infant death syndrome (SIDS)
the best position to place the baby after nursing is
(select all that apply):
1. Prone
2. Side-lying
3. Supine
4. Fowler’s
28. A client has a diagnosis of primary insomnia. Before
assessing this client, the nurse recalls the numerous
causes of this disorder. Select all that apply:
1. Chronic stress
2. Severe anxiety
3. Generalized pain
4. Excessive caffeine
5. Chronic depression
6. Environmental noise
29. Select all that apply to the use of barbiturates in
treating insomnia:
1. Barbiturates deprive people of NREM sleep
2. Barbiturates deprive people of REM sleep
3. When the barbiturates are discontinued, the NREM sleep
increases.
4. When the barbiturates are discontinued, the REM sleep
increases.
5. Nightmares are often an adverse effect when discontinuing
barbiturates.
30. Select all that apply that is appropriate when there
is a benzodiazepine overdose:
1. Administration of syrup of ipecac
2. Gastric lavage
3. Activated charcoal and a saline cathartic
4. Hemodialysis
5. Administration of Flumazenil
Answers and Rationale
1. Answer: 1, 2, and 3
Prothrombin time, partial thromboplastin time, and platelet
count are all included in coagulation studies. The hemoglobin
level, though important information prior to an invasive
procedure like liver biopsy, does not assess coagulation.
2. Answer: 2, 3, and 4
Polycythemia vera is a condition in which the bone marrow
produces too many red blood cells. This causes an increase in
hematocrit and viscosity of the blood. Patients can experience
headaches, dizziness, and visual disturbances. Cardiovascular
effects include increased blood pressure and delayed clotting
time. Weight loss is not a manifestation of polycythemia vera.
3. Answer: 1 and 4.
4. Answers: 2, 3, 4 and 5.
Polycythemia vera, a condition in which too many RBCs are
produced in the blood serum, can lead to an increase in the
hematocrit and hypervolemia, hyperviscosity, and
hypertension. Subsequently, the client can experience
dizziness, tinnitus, visual disturbances, headaches, or a
feeling of fullness in the head. The client may also experience
cardiovascular symptoms such as heart failure (shortness of
breath and orthopnea) and increased clotting time or
symptoms of an increased uric acid level such as painful
swollen joints (usually the big toe). Hearing loss and weight
loss are not manifestations associated with polycythemia
vera.
5. Answer: 1, 3, 5.
A respiratory assessment, which includes auscultation of
breath sounds and assessing the color of the nail beds, is a
priority for clients with pneumonia. Assessing for the presence
of chest pain is also an important respiratory assessment as
chest pain can interfere with the client’s ability to breathe
deeply. Auscultating bowel sounds and assessing for
peripheral edema may be appropriate assessments, but these
are not priority assessments for the patient with pneumonia.
6. Answer: 2, 4, 5.
7. Answer: 2, 3, 4.
Palpitations, an adrenergic symptom, occur as the glucose
levels fall; the sympathetic nervous system is activated and
epinephrine and norepinephrine are secreted causing this
response. Diaphoresis is a sympathetic nervous system
response that occurs as epinephrine and norepinephrine are
released. Slurred speech is a neuroglycopenic symptom; as
the brain receives insufficient glucose, the activity of the CNS
becomes depressed.
8. Answer: 2, 4.
Metabolic acidosis initiates respiratory compensation in the
form of Kussmaul respirations to counteract the effects of
ketone buildup, resulting in a lowered PCO2. A fruity odor to
the breath (acetone breath) occurs when the ketone level is
elevated in ketoacidosis.
9. Answer: 2, 4, and 5.
The nurse can delegate the following basic care activities to
the unlicensed assistant: providing skin care following bowel
movements, maintaining intake and output records, and
obtaining the client’s weight. Assessing the client’s bowel
sounds and evaluating the client’s response to medication are
registered nurse activities that cannot be delegated.
10. Answer: 1 and 3.
HF is a result of structural and functional abnormalities of the
heart tissue muscle. The heart muscle becomes weak and
does not adequately pump the blood out of the chambers. As
a result, blood pools in the left ventricle and backs up into the
left atrium, and eventually into the lungs. Therefore, greater
amounts of blood remain in the ventricle after contraction
thereby decreasing cardiac output. In addition, this pooling
leads to thrombus formation and ineffective tissue perfusion
because of the decrease in blood flow to the other organs and
tissues of the body. Typically, these clients have an ejection
fraction of less than 50% and poorly tolerate activity. Activity
intolerance is related to a decrease, not increase, in cardiac
output. Gas exchange is impaired. However, the decrease in
cardiac output triggers compensatory mechanisms, such as
an increase in sympathetic nervous system activity.
11. Answer: 1, 2, 4, 5.
A major concern with intravenous administration of cytotoxic
agents is vessel irritation or extravasation. The Oncology
Nursing Society and hospital guidelines require frequent
evaluation of blood return when administering vesicant or non
vesicant chemotherapy due to the risk of extravasation.
These guidelines apply to peripheral and central venous lines.
In addition, central venous lines may be long-term venous
access devices. Thus, difficulty drawing or aspirating blood
may indicate the line is against the vessel wall or may
indicate the line has occlusion. Having the client cough or
move position may change the status of the line if it is
temporarily against a vessel wall. Occlusion warrants more
thorough evaluation via x-ray study to verify placement if the
status is questionable and may require a declotting regimen.
12. Answer: 1, 2, 5.
13. Answer: 1, 2, 4.
A client with an impulse control disorder who displays violent,
aggressive, and assaultive behavior generally functions well in
other areas of his life. The degree of aggressiveness is
typically out of proportion with the stressor. Such a client
commonly has a history of parental alcoholism and a chaotic
family life, and often verbalizes sincere remorse and guilt for
the aggressive behavior.
14. Answer: 3.
It is specific in what to do and when.
15. Answer: 1, 2, 4, 5.
If outflow drainage is inadequate, the nurse attempts to
stimulate outflow by changing the client’s position. Turning
the client to the other side or making sure that the client is in
good body alignment may assist with outflow drainage. The
drainage bag needs to be lower than the client’s abdomen to
enhance gravity drainage. The connecting tubing and the
peritoneal dialysis system is also checked for kinks or twisting
and the clamps on the system are checked to ensure that
they are open. There is no reason to contact the physician.
16. Answer: 1, 2, 3.
Appropriate nursing diagnoses for clients with chronic renal
failure include excess fluid volume related to fluid and sodium
retention; imbalanced nutrition, less than body requirements
related to anorexia, nausea, and vomiting; and activity
intolerance related to fatigue. The nursing diagnoses of
impaired gas exchange and pain are not commonly related to
chronic renal failure.
17. Answer: 1, 2, 4.
Head tilt, vomiting, and lethargy are classic signs assessed in
a child with a brain tumor. Clinical manifestations are the
result of location and size of the tumor.
18. Answer: 1, 2, 4, 5.
The client has signs and symptoms of autonomic dysreflexia.
The potentially life-threatening condition is caused by an
uninhibited response from the sympathetic nervous system
resulting from a lack of control over the autonomic nervous
system. The nurse should immediately elevate the HOB to 90
degrees and place extremities dependently to decrease
venous return to the heart and increase venous return from
the brain. Because tactile stimuli can trigger autonomic
dysreflexia, any constrictive clothing should be loosened. The
nurse should also assess for distended bladder and bowel
impaction, which may trigger autonomic dysreflexia, and
correct any problems. Elevated blood pressure is the most
life-threatening complication of autonomic dysreflexia
because it can cause stroke, MI, or seizures. If removing the
triggering event doesn’t reduce the client’s blood pressure, IV
antihypertensives should be administered. A fan shouldn’t be
used because cold drafts may trigger autonomic dysreflexia.
19. Answer: 3, 4.
The client with an ileal conduit must learn self-care activities
related to care of the stoma and ostomy appliances. The
client should be taught to increase fluid intake to about 3,000
ml per day and should not limit intake. Adequate fluid intake
helps to flush mucus from the ileal conduit. The ostomy
appliance should be changed approximately every 3 to 7 days
and whenever a leak develops. A skin barrier is essential to
protecting the skin from the irritation of the urine. An aspirin
should not be used as a method of odor control because it can
be an irritant to the stoma and lead to ulceration. The ostomy
pouch should be emptied when it is one-third to one-half full
to prevent the weight from pulling the appliance away from
the skin.
20. Answers:​ ​1, 4, 5, and 6.
The ​probable​ signs of pregnancy include:
Uterine Enlargement
Hegar’s sign or softening and thinning of the uterine segment
that occurs at week 6.
Goodell’s sign or softening of the cervix that occurs at the
beginning of the 2nd month
Chadwick’s sign or bluish coloration of the mucous
membranes of the cervix, vagina and vulva. Occurs at week
6.
Ballottement or rebounding of the fetus against the
examiner’s fingers of palpation
Braxton-Hicks contractions
Positive pregnancy test measuring for hCG.
Positive signs of pregnancy include:
Fetal Heart Rate detected by electronic device (doppler) at
10-12 weeks
Fetal Heart rate detected by nonelectronic device (fetoscope)
at 20 weeks AOG
Active fetal movement palpable by the examiners
Outline of the fetus via radiography or ultrasound
21. Answer: 1 and 3.
The three classic signs of preeclampsia are hypertension,
generalized edema, and proteinuria. Increased respirations
are not a sign of preeclampsia.
22. Answers: 3, 4, 5, 6, and 7.
When caring for a client receiving magnesium sulfate therapy,
the nurse would monitor maternal vital signs, especially
respirations, every 30-60 minutes and notify the physician if
respirations are less than 12, because this would indicate
respiratory depression. Calcium gluconate is kept on hand in
case of magnesium sulfate overdose, because calcium
gluconate is the antidote for magnesium sulfate toxicity. Deep
tendon reflexes are assessed hourly. Cardiac and renal
function is monitored closely. The urine output should be
maintained at 30 ml per hour because the medication is
eliminated through the kidneys.
23. Answer: 1, 3, 5.
In a client who has had an ECG, the P wave represents the
activation of the electrical impulse in the SA node, which is
then transmitted to the AV node. In addition, the P wave
represents atrial muscle depolarization, not ventricular
depolarization. The normal duration of the P wave is 0.11
seconds or less in duration and 2.5 mm or more in height.
24. Answer: 1, 2, 4, 5.
A major concern with intravenous administration of cytotoxic
agents is vessel irritation or extravasation. The Oncology
Nursing Society and hospital guidelines require frequent
evaluation of blood return when administering vesicant or non
vesicant chemotherapy due to the risk of extravasation.
These guidelines apply to peripheral and central venous lines.
In addition, central venous lines may be long-term venous
access devices. Thus, difficulty drawing or aspirating blood
may indicate the line is against the vessel wall or may
indicate the line has occlusion. Having the client cough or
move position may change the status of the line if it is
temporarily against a vessel wall. Occlusion warrants more
thorough evaluation via x-ray study to verify placement if the
status is questionable and may require a declotting regimen.
25. Answer: 3.
A small glass of milk relaxes the body and promotes sleep.
26. Answer: 1, 3, and 4.
These symptoms are often reported by clients with insomnia.
Clients report nonrestorative sleep. Arising once at night to
urinate (nocturia) is not in and of itself insomnia.
27. Answer: 2 and 3.
Research demonstrate that the occurrence of SIDS is reduced
with these two positions.
28. Answer: 1, 4, and 6.
Acute or primary insomnia is caused by emotional or physical
discomfort not caused by the direct physiologic effects of a
substance or a medical condition. Excessive caffeine intake is
an example of disruptive sleep hygiene; caffeine is a
stimulant that inhibits sleep. Environmental noise causes
physical and/or emotional and therefore is related to primary
insomnia.
29. Answer: 2, 4, and 5.
Barbiturates deprive people of REM sleep. When the
barbiturate is stopped and REM sleep once again occurs, a
rebound phenomenon occurs. During this phenomenon, the
persons dream time constitutes a larger percentage of the
total sleep pattern, and the dreams are often nightmares.
30. Answer: 2, 3, and 5.
If ingestion is recent, decontamination of the GI system is
indicated. The administration of syrup of ipecac is
contraindicated because of aspiration risks related to
sedation. Gastric lavage is generally the best and most
effective means of gastric decontamination. Activated
charcoal and a saline cathartic may be administered to
remove any remaining drug. Hemodialysis is not useful in the
treatment of benzodiazepine overdose. Flumazenil can be
used to acutely reverse the sedative effects of
benzodiazepines, though this is normally done only in cases of
extreme overdose or sedation.
NCLEX SATA 2
1. A 6-year-old child with leukemia is hospitalized and
is receiving combination chemotherapy. Laboratory
results indicate that the child is neutropenic, and the
nurse prepares to implement protective isolation
procedures. Which interventions would the nurse
initiate? Select all that apply.
1. Restrict all visitors.
2. Place the child on a low-bacteria diet.
3. Change dressings using sterile technique.
4. Encourage the consumption of fresh fruits and vegetables.
5. Perform meticulous hand washing before caring for the
child.
6. Allow fresh-cut flowers in the room as long as they are
kept in a vase with fresh water.
2. A 16-year-old child is brought to the emergency
department by his mother with a complaint that the
child just experienced a tonic-clonic seizure. On arrival
in the emergency department no apparent seizures
were occurring. The mother states that her son is
taking medication for the seizure disorder. The nurse
plans care, knowing that which of the following
medications are used for long-term control of
tonic-clonic seizures? Select all that apply.
1. Diazepam (Valium)
2. Alprazolam (Xanax)
3. Gabapentin (Neurontin)
4. Ethosuximide (Zarontin)
5. Carbamazepine (Tegretol)
6. Methylphenidate (Ritalin)
3. A child has been diagnosed with meningococcal
meningitis. Which of the following isolation
techniques is appropriate?
1. Enteric precautions
2. Neutropenic precautions
3. No precautions are required as long as antibiotics have
been started.
4. Isolation precautions for at least 24 hours after the
initiation of antibiotics
4. A client enters the emergency department confused,
twitching, and having seizures. His family states he
recently was placed on corticosteroids for arthritis and
was feeling better and exercising daily. On data
collection, he has flushed skin, dry mucous membranes,
an elevated temperature, and poor skin turgor. His
serum sodium level is 172 mEq/L. Choose the
interventions that the health care provider would likely
prescribe. Select all that apply.
1. Monitor intake and output.
2. Monitor vital signs.
3. Maintain sodium-reduced diet.
4. Monitor electrolyte levels.
5. Increase water intake orally.
6. Administer sodium replacements.
5. A client has died, and a nurse asks a family member
about the funeral arrangements. The family member
refuses to discuss the issue. The nurse’s appropriate
action is to:
1. Show acceptance of feelings.
2. Provide information needed for decision making.
3. Suggest a referral to a mental health professional.
4. Remain with the family member without discussing funeral
arrangements.
6. A client is scheduled for a myelogram, and the nurse
provides a list of instructions to the client regarding
preparation for the procedure. Which instructions
should the nurse place on the list? Select all that apply.
1. Jewelry will need to be removed.
2. An informed consent will need to be signed.
3. A trained x-ray technician performs the procedure.
4. The procedure will take approximately 45 minutes.
5. A liquid diet can be consumed on the day of the procedure.
6. Solid food intake needs to be restricted only on the day of
the procedure.
7. A client with a closed head injury is receiving
phenytoin (Dilantin), an anticonvulsant medication.
Which of the following would indicate that the client is
experiencing side effects related to this medication?
Select all that apply.
1. Ataxia
2. Sedation
3. Constipation
4. Bleeding gums
5. Hyperglycemia
6. Decreased platelet count
8. A client with carcinoma of the lung develops the
syndrome of inappropriate antidiuretic hormone
(SIADH) as a complication of the cancer. The nurse
anticipates that which of the following may be
prescribed? Select all that apply.
1. Radiation
2. Chemotherapy
3. Increased fluid intake
4. Serum sodium blood levels
5. Decreased oral sodium intake
6. Medication that is antagonistic to antidiuretic hormone
(ADH)
9. A client with carcinoma of the lung develops the
syndrome of inappropriate antidiuretic hormone
(SIADH) as a complication of the cancer. The nurse
anticipates that which of the following may be
prescribed? Select all that apply.
1. Radiation
2. Chemotherapy
3. Increased fluid intake
4. Serum sodium blood levels
5. Decreased oral sodium intake
6. Medication that is antagonistic to antidiuretic hormone
(ADH)
10. The clinic nurse is assisting to perform a focused
data collection process on a client who is complaining
of symptoms of a cold, a cough, and lung congestion.
Which of the following would the nurse include for this
type of data collection? Select all that apply.
1. Auscultating lung sounds
2. Obtaining the client’s temperature
3. Checking the strength of peripheral pulses
4. Obtaining information about the client’s respirations
5. Performing a musculoskeletal and neurological examination
6. Asking the client about a family history of any illness or
disease
11. A community health nurse is conducting a teaching
session about terrorism with members of the
community and discussing information regarding
anthrax. The nurse tells those attending that anthrax
can be transmitted via which route(s)? Select all that
apply.
1. Skin
2. Kissing
3. Inhalation
4. Gastrointestinal
5. Direct contact with an infected individual
6. Sexual contact with an infected individual
12. The emergency room nurse is providing discharge
teaching to the parents of a 2-year-old child who
sustained burns from a hot cup of coffee that had been
left on the kitchen counter. The nurse evaluates that
the parents have correctly understood the teaching
when they state which of the following?
1. “We will be sure to not leave hot liquids unattended.”
2. “I guess my child needs to understand what the word ‘hot’
means.”
3. “We will be sure that our child stays in his room when we
work in the kitchen.”
4. “We will install a safety gate as soon as we get home so
that our child can’t get into the kitchen.”
13. A licensed practical nurse is attending an agency
orientation meeting about the nursing model of
practice implemented in the facility. The nurse is told
that the nursing model is a team nursing approach. The
nurse understands that which of the following is a
characteristic of this type of nursing model of practice?
1. A task approach method is used to provide care to clients.
2. Managed care concepts and tools are used when providing
client care.
3. Nursing staff are led by a nurse when providing care to a
group of clients.
4. A single registered nurse is responsible for providing
nursing care to a group of clients.
14. A licensed practical nurse is planning the client
assignments for the day. Which of the following is the
most appropriate assignment for the nursing assistant?
1. A client who requires wound irrigation
2. A client who requires frequent ambulation
3. A client who is receiving continuous tube feedings
4. A client who requires frequent vital signs after a cardiac
catheterization
15. A male client who has heart failure receives an
additional dose of bumetanide as prescribed 4 hours
after the daily dose. The nurse assesses him 15
minutes after administering the medication and
reminds him to save all urine in the bathroom. Thirty
minutes later the nurse finds the client on the floor,
unresponsive, and bleeding from a laceration.
Determine the issues that support the client’s
malpractice claim. Select all that apply.
1. Failure to replace body fluids
2. Increased risk of hypotension
3. Failure to teach the client adequately
4. Increased need to protect the client
5. Excessive bumetanide administration
6. Lack of follow-up nursing actions
16. A nurse develops a plan of care for a client
following a lumbar puncture. Which interventions
should be included in the plan? Select all that apply.
1. Monitor the client’s ability to void.
2. Maintain the client in a flat position.
3. Restrict fluid intake for a period of 2 hours.
4. Monitor the client’s ability to move the extremities.
5. Inspect the puncture site for swelling, redness, and
drainage.
6. Maintain the client on a nothing-by-mouth (NPO) status for
24 hours.
17. A nurse employed in an emergency department is
assigned to assist with the triage of clients arriving to
the emergency department for treatment on the
evening shift. The nurse would assign the highest
priority to which of the following clients?
1. A client complaining of muscle aches, a headache, and
malaise
2. A client who twisted her ankle when she fell while
rollerblading
3. A client with a minor laceration on the index finger
sustained while cutting an eggplant
4. A client with chest pain who states that he just ate pizza
that was made with a very spicy sauce
18. A nurse enters a client’s room and notes that the
client’s lawyer is present and that the client is
preparing a living will. The living will requires that the
client’s signature be witnessed, and the client asks the
nurse to witness the signature. Which of the following
is the appropriate nursing action?
1. Decline to sign the will.
2. Sign the will as a witness to the signature only.
3. Call the hospital lawyer before signing the will.
4. Sign the will, clearly identifying credentials and
employment agency.
19. A nurse has reinforced instructions to the client
with hyperparathyroidism regarding home care
measures related to exercise. Which statement by the
client indicates a need for further instruction? Select all
that apply.
1. “I enjoy exercising but I need to be careful.”
2. “I need to pace my activities throughout the day.”
3. “I need to limit playing football to only the weekends.”
4. “I should gauge my activity level by my energy level.”
5. “I should exercise in the evening to encourage a good
sleep pattern.”
20. A nurse in a medical unit is caring for a client with
heart failure. The client suddenly develops extreme
dyspnea, tachycardia, and lung crackles, and the nurse
suspects pulmonary edema. The nurse immediately
notifies the registered nurse and expects which
interventions to be prescribed? Select all that apply.
1. Administering oxygen
2. Inserting a Foley catheter
3. Administering furosemide (Lasix)
4. Administering morphine sulfate intravenously
5. Transporting the client to the coronary care unit
6. Placing the client in a low Fowler’s side-lying position
Answers and Rationale
1. Answer: 2, 3, and 5.
For the hospitalized neutropenic child, flowers or plants
should not be kept in the room because standing water and
damp soil harbor Aspergillus and Pseudomonas, to which
these children are very susceptible. Fruits and vegetables not
peeled before being eaten harbor molds and should be
avoided until the white blood cell count rises. The child is
placed on a low-bacteria diet. Dressings are always changed
with sterile technique. Not all visitors need to be restricted,
but anyone who is ill should not be allowed in the child’s
room. Meticulous hand washing is required before caring for
the child. In addition, gloves, a mask, and a gown are worn
(per agency policy).
2. Answers: 3, 4, and 5.
Medications that are prescribed for long-term control of
tonic-clonic seizures are gabapentin, ethosuximide, and
carbamazepine. Diazepam is a medication that is prescribed
to halt tonic-clonic episodes, and methylphenidate is a
medication used to treat attention deficit hyperactivity
disorder. Both of these medications are not suitable for
long-term control of a seizure condition. Alprazolam is a
medication used to treat anxiety.
3. Answer: 4.
Meningococcal meningitis is transmitted primarily by droplet
infection. Isolation is begun and maintained for at least 24
hours after antibiotics are given. Options 1, 2, and 3 are
incorrect.
4. Answers: 1, 2, 3, 4, and 5.
Hypernatremia is described as having a serum sodium level
that exceeds 145 mEq/L. Signs and symptoms would include
dry mucous membranes, loss of skin turgor, thirst, flushed
skin, elevated temperature, oliguria, muscle twitching,
fatigue, confusion, and seizures. Interventions include
monitoring fluid balance, monitoring vital signs, reducing
dietary intake of sodium, monitoring electrolyte levels, and
increasing oral intake of water. Sodium replacement therapy
would not be prescribed for a client with hypernatremia.
5. Answer: 4.
The family member is exhibiting the first stage of grief
(denial), and the nurse should remain with the family
member. Option 1 is an appropriate intervention for the
acceptance or reorganization and restitution stage. Option 2
may be an appropriate intervention for the bargaining stage.
Option 3 may be an appropriate intervention for depression.
6. Answer: 1, 2, and 4.
Client preparation for a myelogram includes instructing the
client to restrict food and fluids for 4 to 8 hours before the
procedure. The client is told that the procedure takes about
45 minutes. An informed consent is required because the
procedure is invasive and is therefore performed by the
health care provider. The client will need to remove jewelry
and metal objects from the chest area. The client is also told
that pretest medications may be prescribed for relaxation.
7. Answers: 3, 4, 5, and 6.
Dilantin causes blood dyscrasias, such as decreased platelet
counts and decreased white blood cell counts; it contributes
to constipation as well. Gingival hyperplasia can occur,
causing gums to bleed easily, and blood glucose levels can
elevate when taking phenytoin. Sedation is a side effect of
barbiturates, not phenytoin. Ataxia is a side effect of
benzodiazepines.
8. Answers: 1, 2, 4, and 6.
Cancer is a common cause of SIADH. In clients with SIADH,
excessive amounts of water are reabsorbed by the kidney and
put into the systemic circulation. The increased water causes
hyponatremia (decreased serum sodium levels) and some
degree of fluid retention. SIADH is managed by treating the
condition and its cause, and treatment usually includes fluid
restriction, increased sodium intake, and a medication with a
mechanism of action that is antagonistic to ADH. Sodium
levels are monitored closely, because hypernatremia can
suddenly develop as a result of treatment. The immediate
institution of appropriate cancer therapy (usually either
radiation or chemotherapy) can cause tumor regression so
that ADH
synthesis and release processes return to normal.
9. Answers: 1, 2, 4 and 6.
Cancer is a common cause of SIADH. In clients with SIADH,
excessive amounts of water are reabsorbed by the kidney and
put into the systemic circulation. The increased water causes
hyponatremia (decreased serum sodium levels) and some
degree of fluid retention. SIADH is managed by treating the
condition and its cause, and treatment usually includes fluid
restriction, increased sodium intake, and a medication with a
mechanism of action that is antagonistic to ADH. Sodium
levels are monitored closely, because hypernatremia can
suddenly develop as a result of treatment. The immediate
institution of appropriate cancer therapy (usually either
radiation or chemotherapy) can cause tumor regression so
that ADH synthesis and release processes return to normal.
10. Answers: 1, 2, and 4.
A focused data collection process focuses on a limited or
short-term problem, such as the client’s complaint. Because
the client is complaining of symptoms of a cold, a cough, and
lung congestion the nurse would focus on the respiratory
system and the presence of an infection. A complete data
collection includes a complete health history and physical
examination and forms a baseline database. Checking the
strength of peripheral pulses relates to a vascular
assessment, which is not related to this client’s complaints. A
musculoskeletal and neurological examination also is not
related to this client’s complaints. However, strength of
peripheral pulses and a musculoskeletal and neurological
examination would be included in a complete data collection.
Likewise, asking the client about a family history of any illness
or disease would be included in a complete assessment.
11. Answers: 1, 3, and 4.
Anthrax is caused by Bacillus anthracis, and it can be
contracted through the digestive system, abrasions in the
skin, or inhalation. It cannot be spread from person to
person.
12. Answer: 1.
Toddlers, with their increased mobility and developing motor
skills, can reach hot water, open fires, or hot objects placed
on counters and stoves above their eye level. Parents should
be encouraged to remain in the kitchen when preparing a
meal and reminded to use the back burners on the stove. Pot
handles should be turned inward and toward the middle of the
stove. Hot liquids should never be left unattended, and the
toddler should always be supervised. Options 2, 3, and 4 do
not reflect an adequate understanding of the principles of
safety.
13. Answer: 3.
In team nursing, nursing personnel are led by a nurse when
providing care to a group of clients. Option 1 identifies
functional nursing. Option 2 identifies a component of case
management. Option 4 identifies primary nursing.
14. Answer: 2.
The nurse must determine the most appropriate assignment
on the basis of the skills of the staff member and the needs of
the client. In this case, the most appropriate assignment for a
nursing assistant would be to care for the client who requires
frequent ambulation. The nursing assistant is skilled in this
task. The
client who had a cardiac catheterization will require specific
monitoring in addition to that of the vital signs. Wound
irrigations and tube feedings are not performed by unlicensed
personnel.
15. Answers: 2, 3, 4, and 6.
To prove malpractice against a nurse, the plaintiff must prove
that the nurse owed a duty to the client, that the nurse
breached the duty, and that as a result harm was caused to
person or property. The client has an increased risk of
hypotension (option 2) because hypotension is a common
adverse effect of bumetanide, this is the second dose within 4
hours, and the client has heart failure. The client can prove
that the nurse did not protect him by failing to provide
adequate teaching and perform correct and timely nursing
interventions (options 3, 4, and 6) after administering the
bumetanide. After the first 15-minute check, the nurse should
continue increased client monitoring to ensure client
compliance with safety measures. Replacing fluid volume is
not the issue; furthermore, the goal of therapy is to reduce
total body fluid. No data indicate that the dose of bumetanide,
a loop diuretic, was excessive. However, because this
medication can cause hypotension, especially after a repeat
dose, the nurse should instruct the client to remain in bed and
provide him with a urinal. It may be difficult for the client to
prove that the second dose of bumetanide caused the injury.
16. Answers: 1, 2, 4, and 5.
Following a lumbar puncture, the client remains flat in bed for
6 to 24 hours, depending on the health care provider’s
prescriptions. A liberal fluid intake (not NPO status) is
encouraged to replace cerebrospinal fluid removed during the
procedure, unless contraindicated by the client’s condition.
The nurse checks the puncture site for redness and drainage,
and monitors the client’s ability to void and move the
extremities.
17. Answers: 4.
In an emergency department, triage involves classifying
clients according to their need for care, and it includes
establishing priorities of care. The type of illness, the severity
of the problem, and the resources available govern the
process. Clients with trauma, chest pain, severe respiratory
distress, cardiac arrest, limb amputation, or acute
neurological deficits and those who sustained a chemical
splash to the eyes are classified as emergent, and these
clients are the number 1 priority. Clients with conditions such
as simple fractures, asthma without respiratory distress,
fever, hypertension, abdominal pain, or renal stones have
urgent needs, and these clients are classified as the number 2
priority. Clients with conditions such as minor lacerations,
sprains, or cold symptoms are classified as non urgent, and
they are the number 3
priority.
18. Answers: 1
Living wills are required to be in writing and signed by the
client. The client’s signature either must be witnessed by
specified individuals or notarized. Many states prohibit any
employee from being a witness, including a nurse in a facility
in which the client is receiving care.
19. Answers: 3 and 5.
The client should be instructed to avoid high-impact activity
or contact sports such as football. Exercising late in the
evening may interfere with restful sleep. The client with
hyperparathyroidism should pace activities throughout the
day and plan for periods of uninterrupted rest. The client
should plan for at least 30 minutes of walking each day to
support calcium movement into the bones. The client should
be instructed to use energy level as a guide to activity.
20. Answers: 1, 2, 3, and 4.
Pulmonary edema is a life-threatening event that can result
from severe heart failure. In pulmonary edema the left
ventricle fails to eject sufficient blood, and pressure increases
in the lungs because of the accumulated blood. Oxygen is
always prescribed, and the client is placed in a high Fowler’s
position to ease the work of breathing. Furosemide, a
rapid-acting diuretic, will eliminate accumulated fluid. A Foley
catheter is inserted to accurately measure output.
Intravenously administered morphine sulfate reduces venous
return (preload), decreases anxiety, and reduces the work of
breathing. Transporting the client to the coronary care unit is
not a priority intervention. In fact, this may not be necessary
at all if the client’s response to treatment is successful.
NCLEX SATA 3
1. A nurse is admitting a client with a possible
diagnosis of chronic bronchitis. The nurse collects data
from the client and notes that which of the following
signs supports this diagnosis? Select all that apply.
1. Scant mucus
2. Early onset cough
3. Marked weight loss
4. Purulent mucus production
5. Mild episodes of dyspnea
2. A nurse is assigned to care for a client admitted to
the hospital after sustaining an injury from a house
fire. The client attempted to save a neighbor involved
in the fire but, in spite of the client’s efforts, the
neighbor died. Which action would the nurse take to
enable the client to work through the meaning of the
crisis?
1. Identifying the client’s ability to function
2. Identifying the client’s potential for self-harm
3. Inquiring about the client’s feelings that may affect coping
4. Inquiring about the client’s perception of the cause of the
neighbor’s death
3. A nurse is assigned to care for a client with a
peripheral IV infusion. The nurse is providing hygiene
care to the client and would avoid which of the
following while changing the client’s hospital gown?
1. Using a hospital gown with snaps at the sleeves
2. Disconnecting the IV tubing from the catheter in the vein
3. Checking the IV flow rate immediately after changing the
hospital gown
4. Putting the bag and tubing through the sleeve, followed by
the client’s arm
4. A nurse is assigned to care for four clients. When
planning client rounds, which client would the nurse
check first?
1. A client on a ventilator
2. A client in skeletal traction
3. A postoperative client preparing for discharge
4. A client admitted on the previous shift who has a diagnosis
of gastroenteritis
5. A nurse is assisting with collecting data from an
African-American client admitted to the ambulatory
care unit who is scheduled for a hernia repair. Which of
the following information about the client is of least
priority during the data collection?
1. Respiratory
2. Psychosocial
3. Neurological
4. Cardiovascular
6. A nurse is assisting with planning care for a client
with an internal radiation implant. Which of the
following should be included in the plan of care? Select
all that apply.
1. Wearing gloves when emptying the client’s bedpan
2. Keeping all linens in the room until the implant is removed
3. Wearing a film (dosimeter) badge when in the client’s room
4. Wearing a lead apron when providing direct care to the
client
5. Placing the client in a semiprivate room at the end of the
hallway
7. The nurse is caring for a client after a supratentorial
craniotomy in which a large tumor was removed from
the left side. Choose the positions in which the nurse
can safely place the client. Select all that apply.
1. On the left side
2. With the neck flexed
3. Supine on the left side
4. With extreme hip flexion
5. In a semi-Fowler’s position
6. With the head in a midline position
8. A nurse is caring for a client after thyroidectomy and
notes that calcium gluconate is prescribed for the
client. The nurse determines that this medication has
been prescribed to:
1. Treat thyroid storm.
2. Prevent cardiac irritability.
3. Treat hypocalcemic tetany.
4. Stimulate the release of parathyroid hormone.
9. A nurse is caring for a client with a
healthcare-associated infection caused by
methicillin-resistant Staphylococcus aureus who is on
contact precautions. The nurse prepares to provide
colostomy care to the client. Which of the following
protective items will be required to perform this
procedure?
1. Gloves and a gown
2. Gloves and goggles
3. Gloves, a gown, and goggles
4. Gloves, a gown, and shoe protectors
10. A nurse is caring for a client with a nasogastric tube
that is attached to low suction. The nurse monitors the
client closely for which acid-base disorder that is most
likely to occur in this situation?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis
11. A nurse is caring for a client with diabetic
ketoacidosis and documents that the client is
experiencing Kussmaul’s respirations. Based on this
documentation, which of the following did the nurse
most likely observe?
1. Respirations that cease for several seconds
2. Respirations that are regular but abnormally slow
3. Respirations that are labored and increased in depth and
rate
4. Respirations that are abnormally deep, regular, and
increased in rate
12. Which nursing interventions are appropriate for a
client recovering from surgery for retinal detachment?
Select all that apply.
1. Monitor for hemorrhage.
2. Administer eye medications.
3. Maintain the eye patch or shield.
4. Assist with activities of daily living.
5. Encourage coughing and deep breathing.
6. Educate regarding symptoms of retinal detachment.
13. A nurse is caring for a client with leukemia and
notes that the client has poor skin turgor and flat neck
and hand veins. The nurse suspects hyponatremia.
What additional signs would the nurse expect to note in
this client if hyponatremia is present?
1. Intense thirst
2. Slow bounding pulse
3. Dry mucous membranes
4. Postural blood pressure changes
14. A nurse is caring for a group of clients who are
taking herbal medications at home. Which of the
following clients should be instructed not to take herbal
medications?
1. A 60-year-old male client with rhinitis
2. A 24-year-old male client with a lower back injury
3. A 10-year-old female client with a urinary tract infection
4. A 45-year-old female client with a history of migraine
headaches
15. A nurse is caring for an infant with a diagnosis of
tetralogy of Fallot. The infant suddenly becomes
cyanotic and the oxygen saturation reading drops to
60%. Choose the interventions that the nurse should
perform. Select all that apply.
1. Call a code blue.
2. Notify the registered nurse.
3. Place the infant in a prone position.
4. Prepare to administer morphine sulfate.
5. Prepare to administer intravenous fluids.
6. Prepare to administer 100% oxygen by face mask.
16. A nurse is collecting data on a client with severe
preeclampsia. Choose the findings that would be noted
in severe preeclampsia. Select all that apply.
1. Oliguria
2. Seizures
3. Contractions
4. Proteinuria 3+
5. Muscle cramps
6. Blood pressure 168/116 mm Hg
17. A nurse is monitoring a client with Graves’ disease
for signs of thyrotoxicosis (thyroid storm). Which of
the following signs and symptoms, if noted in the
client, will alert the nurse to the presence of this crisis?
Select all that apply.
1. Bradycardia
2. Fever
3. Sweating
4. Agitation
5. Pallor
18. A nurse is monitoring a group of clients for
acid-base imbalances. Which clients are at highest risk
for metabolic acidosis? Select all that apply.
1. Severely anxious client
2. Pneumonia client
3. Diabetic mellitus client
4. Malnourished client
5. Asthma client
6. Renal failure client
19. The nurse is preparing a teaching plan for a client
who is undergoing cataract extraction with intraocular
implant. Which home care measures will the nurse
include in the plan? Select all that apply.
1. To avoid activities that require bending over
2. To contact the surgeon if eye scratchiness occurs
3. To place an eye shield on the surgical eye at bedtime
4. That episodes of sudden severe pain in the eye is expected
5. To contact the surgeon if a decrease in visual acuity occurs
6. To take acetaminophen (Tylenol) for minor eye discomfort
20. The nurse is preparing a teaching plan for a client
who is undergoing cataract extraction with intraocular
implant. Which home care measures will the nurse
include in the plan? Select all that apply.
1. To avoid activities that require bending over
2. To contact the surgeon if eye scratchiness occurs
3. To place an eye shield on the surgical eye at bedtime
4. That episodes of sudden severe pain in the eye is expected
5. To contact the surgeon if a decrease in visual acuity occurs
6. To take acetaminophen (Tylenol) for minor eye discomfort
Answers and Rationale
1. Answers: 2, 4, and 5.
Key features of pulmonary emphysema include dyspnea that
is often marked, late cough (after onset of dyspnea), scant
mucus production, and marked weight loss. By contrast,
chronic bronchitis is characterized by an early onset of cough
(before dyspnea), copious purulent mucus production,
minimal weight loss, and milder severity of dyspnea.
2. Answer: 3.
The client must first deal with feelings and negative responses
before the client is able to work through the meaning of the
crisis. Option 3 pertains directly to the client’s feelings.
Options 1, 2, and 4 do not directly address the client’s
feelings.
3. Answer: 2.
The tubing should not be removed from the IV catheter. With
each break in the system, there is an increased chance of
introducing bacteria into the system, which can lead to
infection. Options 1 and 4 are appropriate. The flow rate
should be checked immediately after changing the hospital
gown, because the position of the roller clamp may have been
affected during the change.
4. Answer: 1.
The airway is always a high priority, and the nurse first
checks the client on a ventilator. The clients described in
options 2, 3, and 4 have needs that would be identified as
intermediate priorities.
5. Answer: 2.
The psychosocial data is the least priority during the initial
admission data collection. In the African-American culture, it
is considered intrusive to ask personal questions during the
initial contact or meeting. Additionally, respiratory,
neurological, and cardiovascular data include physiological
assessments that
would be the priority.
6. Answer: 1, 2, 3, and 4.
A private room with a private bath is essential if a client has
an internal radiation implant. This is necessary to prevent the
accidental exposure of other clients to radiation. The
remaining options identify interventions that are necessary for
a client with a radiation device.
7. Answers: 5 and 6.
Clients who have undergone supratentorial surgery should
have the head of the bed elevated 30 degrees to promote
venous drainage from the head. The client is positioned to
avoid extreme hip or neck flexion, and the head is maintained
in a midline, neutral position. If a large tumor has been
removed, the client should be placed on the nonoperative side
to prevent the displacement of the cranial contents.
8. Answer: 3.
9. Answer: 3.
Goggles are worn to protect the mucous membranes of the
eye during interventions that may produce
splashes of blood, body fluids, secretions, and excretions. In
addition, contact precautions require the use of gloves, and a
gown should be worn if direct client contact is anticipated.
Shoe protectors are not
necessary.
10. Answer: 2
The loss of gastric fluid via nasogastric suction or vomiting
causes metabolic alkalosis as a result of the loss of
hydrochloric acid; this results in an alkalotic condition.
Options 3 and 4 deal with respiratory problems. Option 1
relates to acidosis.
11. Answer: 4.
Kussmaul’s respirations are abnormally deep, regular, and
increased in rate. In apnea, respirations cease for several
seconds. In bradypnea, respirations are regular but
abnormally slow. In hyperpnea, respirations are labored and
increased in depth and rate.
12. Answers: 1, 2, 3, 4, and 6.
An eye patch or shield is applied to protect the eye and
prevent any further detachment. Educating the client
regarding symptoms is necessary because the client is at risk
for subsequent retinal detachment. Positioning, activity
restrictions, and eye patches hinder the client in the
performance of activities of daily living, and the client needs
the nurse’s assistance with these activities. Eye medications
are prescribed postoperatively, and hemorrhage is also a risk
post surgery. Coughing is not encouraged because this can
increase intraocular pressure and harm the client.
13. Answer: 4.
Postural blood pressure changes occur in the client with
hyponatremia. Dry mucous membranes
and intense thirst are seen in clients with hypernatremia. A
slow, bounding pulse is not indicative of hyponatremia. In a
client with hyponatremia, a rapid thready pulse is noted.
14. Answer: 3.
Children should not be given herbal therapies, especially in
the home and without professional
supervision. There are no general contraindications for the
clients described in options 1, 2, and 4.
15. Answers: 2, 4, 5, and 6.
The child who is cyanotic with oxygen saturations dropping to
60% is having a hypercyanotic episode. Hypercyanotic
episodes often occur among infants with tetralogy of Fallot,
and they may occur among infants whose heart defect
includes the obstruction of pulmonary blood flow and
communication between the ventricles. If a hypercyanotic
episode occurs, the infant is placed in a knee-chest position
immediately. The registered nurse is notified, who will then
contact the health care provider. The knee-chest position
improves systemic arterial oxygen saturation by decreasing
venous return so that smaller amounts of highly saturated
blood reach the heart. Toddlers and children squat to get into
this position and relieve chronic hypoxia. There is no reason
to call a code blue unless respirations cease. Additional
interventions include administering 100% oxygen by face
mask, morphine sulfate, and intravenous fluids, as
prescribed.
16. Answers: 1, 4, and 6.
Severe preeclampsia is characterized by blood pressure
higher than 160/110 mm Hg, proteinuria 3+ or higher, and
oliguria. Seizures (convulsions) are present in eclampsia and
are not a characteristic of severe preeclampsia. Muscle
cramps and contractions are not findings noted in severe
preeclampsia, although the client is monitored for these
occurrences.
17. Answers: 2, 3, and 4.
Thyrotoxic crisis (thyroid storm) is an acute, potentially
life-threatening state of extreme thyroid activity that
represents a breakdown in the body’s tolerance to a chronic
excess of thyroid hormones. The clinical manifestations
include fever greater than 100° F, severe tachycardia,
flushing and sweating, and marked agitation and restlessness.
Delirium and coma can occur.
18. Answers: 3, 4, and 6.
Diabetes mellitus, malnutrition, and renal failure lead to
metabolic acidosis because of the increasing acids in the
body. Options 1, 2, and 5 are respiratory problems, not
metabolic, and result in either respiratory acidosis or
respiratory alkalosis.
19. Answers: 1, 3, 5, and 6.
After eye surgery, some scratchiness and mild eye discomfort
may occur in the operative eye and is usually relieved by mild
analgesics. If the eye pain becomes severe, the client should
notify the surgeon because this may indicate hemorrhage,
infection, or increased intraocular pressure. The nurse would
also instruct the client to notify the surgeon of purulent
drainage, increased redness, or any decrease in visual acuity.
The client is instructed to place an eye shield over the
operative eye at bedtime to protect the eye from injury during
sleep and to avoid activities that increase intraocular pressure
such as bending over.
20. Answers: 1, 3, 5, and 6.
After eye surgery, some scratchiness and mild eye discomfort
may occur in the operative eye and is usually relieved by mild
analgesics. If the eye pain becomes severe, the client should
notify the surgeon because this may indicate hemorrhage,
infection, or increased intraocular pressure. The nurse would
also instruct the client to notify the surgeon of purulent
drainage, increased redness, or any decrease in visual acuity.
The client is instructed to place an eye shield over the
operative eye at bedtime to protect the eye from injury during
sleep and to avoid activities that increase intraocular pressure
such as bending over.
NCLEX SATA 4
1. A nurse is providing a list of instructions to a client
who is scheduled to have an electroencephalogram
(EEG). Choose the instructions that the nurse places on
the list. Select all that apply.
1. Cola is acceptable to drink on the day of the test.
2. Tea and coffee are restricted on the day of the test.
3. The test will take between 45 minutes and 2 hours.
4. The hair should be washed the evening before the test.
5. All medications need to be withheld on the day of the test.
6. A nothing-by-mouth (NPO) status is required on the day of
the test.
2. The nurse is providing discharge teaching to the
client who was given a prescription for nifedipine
(Adalat) for blood pressure management. Which
instructions should the nurse include? Select all that
apply.
1. “Increase water intake.”
2. “Increase calcium intake.”
3. “Take pulse rate each day.”
4. “Weigh at the same time each day.”
5. “Palpitations may occur early in therapy.”
6. “Be careful when rising from sitting to standing.”
3. A nurse is providing teaching regarding the
prevention of Lyme disease to a group of teenagers
going on a hike in a wooded area. Which of the
following points should the nurse include in the
session? Select all that apply.
1. Tuck pant legs into socks.
2. Wear closed shoes when hiking.
3. Apply insect repellent containing DEET.
4. Cover the ground with a blanket when sitting.
5. Remove attached ticks by grasping with thumb and
forefinger.
6. Wear long sleeves and long pants in dark colors when in
high-risk areas.
4. A nurse is reinforcing instructions to a client
following a total laryngectomy about caring for the
stoma. Choose the instructions that the nurse provides
to the client. Select all that apply.
1. Protect the stoma from water.
2. Soaps should be avoided near the stoma.
3. Wash the stoma daily using a washcloth.
4. Use diluted alcohol on the stoma to clean it.
5. Apply a thin layer of petroleum jelly to the skin surrounding
the stoma.
6. Use soft tissues to clean any secretions that accumulate
around the stoma.
5. A nurse is reviewing the health records of assigned
clients. The nurse plans care knowing that which client
is at risk for fluid volume deficit?
1. The client with cirrhosis
2. The client with a colostomy
3. The client with decreased kidney function
4. The client with congestive heart failure (CHF)
6. A nurse is told in report that a client has a positive
Chvostek’s sign. What other data would the nurse
expect to find on data collection? Select all that apply.
1. Coma
2. Tetany
3. Diarrhea
4. Possible seizure activity
5. Hypoactive bowel sounds
6. Positive Trousseau’s sign
7. A nurse lawyer provides an education session to the
nursing staff regarding client rights. A nurse asks the
lawyer to describe an example that may relate to
invasion of client privacy. A nursing action that
indicates a violation of this right is:
1. Threatening to place a client in restraints
2. Performing a surgical procedure without consent
3. Taking photographs of the client without consent
4. Telling the client that he or she cannot leave the hospital
8. A nurse notes in the medical record that a client with
Cushing’s syndrome is experiencing fluid overload.
Which interventions should be included in the plan of
care? Select all that apply.
1. Monitoring daily weight
2. Monitoring intake and output
3. Maintaining a low-potassium diet
4. Monitoring extremities for edema
5. Maintaining a low-sodium diet
9. A nurse notes in the medical record that a client with
Cushing’s syndrome is experiencing fluid overload.
Which interventions should be included in the plan of
care? Select all that apply.
1. Monitoring daily weight
2. Monitoring intake and output
3. Maintaining a low-potassium diet
4. Monitoring extremities for edema
5. Maintaining a low-sodium diet
10. Which instruction should the nurse provide to the
client with diabetes mellitus receiving acarbose
(Precose)? Select all that apply.
1. “Take the medication at bedtime.”
2. “Take the medication with each meal.”
3. “Take the medication on an empty stomach.”
4. “Side effects include abdominal bloating and flatus.”
5. “Take some form of glucose if hypoglycemia occurs.”
6. “Report symptoms such as shortness of breath or
tiredness.”
11. A nurse prepares a list of home care instructions for
the parents of a child who has a plaster cast applied to
the left forearm. Choose the instructions that would be
included on the list. Select all that apply.
1. Use the fingertips to lift the cast while it is drying.
2. Keep small toys and sharp objects away from the cast.
3. Use a padded ruler or another padded object to scratch the
skin under the cast if it itches.
4. Place a heating pad on the lower end of the cast and over
the fingers if the fingers feel cold.
5. Contact the health care provider if the child complains of
numbness or tingling in the extremity.
6. Elevate the extremity on pillows for the first 24 to 48 hours
after casting to prevent swelling.
12. A nurse reinforces instructions to the mother of a
child who has been hospitalized with croup. Which of
the following statements, if made by the mother, would
indicate the need for further instruction?
1. “I will give my child cough syrup if a cough develops.”
2. “During an attack, I will take my child to a cool location.”
3. “I will give acetaminophen (Tylenol) if my child develops a
fever.”
4. “I will be sure that my child drinks at least three to four
glasses of fluids every day.”
13. The nurse would anticipate the use of which
medications in the treatment of the client with heart
failure? Select all that apply.
1. Diuretics
2. Anticoagulants
3. Anticholinergics
4. Cardiac glycosides
5. Phosphodiesterase (PDE) inhibitors
6. Angiotensin-converting enzyme (ACE) inhibitors
14. The parent of a toddler asks a nurse when it is safe
to place the car safety seat in a face-forward position.
Which of the following is the best nursing response?
1. When the toddler weighs 20 lb and is 1 year old
2. When the weight of the toddler is more than 40 lb
3. The seat should not be placed in a face-forward position
unless there are safety locks in the car.
4. The seat should never be placed in a face-forward position
because of the risk of the child unbuckling the harness.
15. A pregnant woman has a positive history of genital
herpes, but she has not had lesions during her
pregnancy. The nurse plans to provide which of the
following information to the client?
1. “You will be isolated from your newborn after delivery.”
2. “There is little risk to your baby during your pregnancy,
birth, and after delivery.”
3. “Vaginal deliveries can reduce neonatal infection risks,
even if you have an active lesion at birth.”
4. “You will be evaluated at the time of delivery for herpetic
genital tract lesions. If they are present, a cesarean delivery
will be needed.”
16. Which of these clients are most likely to develop
fluid (circulatory) overload? Select all that apply.
1. A premature infant
2. A 101-year-old man
3. A client on renal dialysis
4. A client with diabetes mellitus
5. A 29-year-old woman with pneumonia
6. A client with congestive heart failure
17. An unconscious client who is bleeding profusely is
brought to the emergency department after a serious
accident. Surgery is required immediately to save the
client’s life. With regard to informed consent for the
surgical procedure, which of the following is the best
action?
1. Call the nursing supervisor to initiate a court order for the
surgical procedure.
2. Try calling the client’s spouse to obtain telephone consent
before the surgical procedure.
3. Ask the friend who accompanied the client to the
emergency department to sign the consent form.
4. Transport the client to the operating department
immediately, as required by the health care provider without
obtaining an informed consent.
18. When caring for a 3-year-old child, the nurse
should provide which toy for this child?
1. A puzzle
2. A wagon
3. A golf set
4. A farm set
19. When the nurse is collecting data from the older
adult, which of the following findings would be
considered normal physiological changes? Select all
that apply.
1. Increased heart rate
2. Decline in visual acuity
3. Decreased respiratory rate
4. Decline in long-term memory
5. Increased susceptibility to urinary tract infections
6. Increased incidence of awakening after sleep onset
20. Which data indicates to the nurse that a client may
be experiencing ineffective coping?
1. Constantly neglects personal grooming
2. Visits her husband’s grave once a month
3. Visits the senior citizens’ center once a month
4. Frequently looks at snapshots of her husband and family
Answers and Rationale
1. Answers: 2, 3, and 4.
Pre-procedure instructions include informing the client that
the procedure is painless. The procedure requires no dietary
restrictions other than avoidance of cola, tea, and coffee on
the morning of the test. These products have a stimulating
effect and should be avoided. The hair should be washed the
evening before the test, and gels, hairsprays, and lotion
should be avoided. The client is informed that the test will
take 45 minutes to 2 hours and that medications are usually
not withheld before the test.
2. Answers: 3, 4, 5, and 6.
Nifedipine is a calcium-channel blocker. Its therapeutic
outcome is to decrease blood pressure. Its method of action is
blockade of the calcium channels in vascular smooth muscle,
promoting vasodilation. Side effects that can occur early in
therapy include reflex tachycardia (palpitations) and first-dose
hypotension, leading to orthostatic hypotension. Weight
should be checked regularly to monitor for early signs of heart
failure. Also the client is taught to take his or her own pulse.
Nifedipine does not affect serum calcium levels. Increased
water intake is not indicated in the client with cardiovascular
disease.
3. Answers: 1, 2, 3, and 4.
Measures to prevent tick bites focus on covering the body as
completely as possible and spraying insect repellent
containing DEET on the skin and clothing. Long sleeves and
pants tucked into the socks along with closed shoes will offer
some protection. Light-colored clothing should be worn so
that ticks would be easily visible. Hikers should not sit directly
on the ground and should cover the ground with an item such
as a blanket. Ticks should be removed with tweezers.
4. Answers: 1, 2, 3, and 5.
The client with a stoma should be instructed to wash the
stoma daily with a washcloth. Soaps, cotton swabs, or tissues
should be avoided because their particles may enter and
obstruct the airway. The client should be instructed to avoid
applying alcohol to a stoma because it is both drying and
irritating. A thin layer of petroleum jelly applied to the skin
around the stoma helps prevent cracking. The client is
instructed to protect the stoma from water.
5. Answer 2.
Causes of a fluid volume deficit include vomiting, diarrhea,
conditions that cause increased respirations or increased
urinary output, insufficient intravenous fluid replacement,
draining fistulas, ileostomy, and colostomy. A client with
cirrhosis, CHF, or decreased kidney function is at risk for fluid
volume excess.
6. Answers: 2, 3, 4 and 6.
A positive Chvostek’s sign is indicative of hypocalcemia. Other
signs and symptoms include tachycardia, hypotension,
paresthesias, twitching, cramps, tetany, seizures, positive
Trousseau’s sign, diarrhea, hyperactive bowel sounds, and a
prolonged QT interval.
7. Answer: 3.
Invasion of privacy takes place when an individual’s private
affairs are intruded on unreasonably. Threatening to place a
client in restraints constitutes assault. Performing a surgical
procedure without consent is an example of battery. Not
allowing a client to leave the hospital constitutes false
imprisonment.
8. Answers: 1, 2, 4, and 5.
The client with Cushing’s syndrome experiencing fluid
overload should be maintained on a high-potassium and
low-sodium diet. Decreased sodium intake decreases renal
retention of sodium and water. Monitoring weight, intake,
output, and extremities for edema are all appropriate
interventions for such a nursing diagnosis.
9. Answers: 1, 2, 4, and 5.
The client with Cushing’s syndrome experiencing fluid
overload should be maintained on a high-potassium and
low-sodium diet. Decreased sodium intake decreases renal
retention of sodium and water. Monitoring weight, intake,
output, and extremities for edema are all appropriate
interventions for such a nursing diagnosis.
10. Answers: 2, 4, 5, and 6.
The mechanism of action of acarbose is a delay in absorption
of dietary carbohydrates, thereby reducing the rise in blood
glucose after a meal. To accomplish this, the medication must
be taken with each meal. Because of its bacterial
fermentation of unabsorbed carbohydrates in the colon, side
effects such as borborygmus, cramps, abdominal distention,
and flatulence can occur. The medication also can affect
absorption of iron, leading to symptoms (shortness of breath,
tiredness) of anemia.
11. Answers: 2, 5, and 6.
While the cast is drying, the palms of the hands are used to
lift the cast. If the fingertips are used, indentations in the cast
could occur and cause constant pressure on the underlying
skin. Small toys and sharp objects are kept away from the
cast, and no objects (including padded objects) are placed
inside of the cast because of the risk of altered skin integrity.
A heating pad is not applied to the cast or fingers. Cold
fingers could indicate neurovascular impairment, and the HCP
should be notified. The extremity is elevated to prevent
swelling, and the HCP is notified immediately if any signs of
neurovascular impairment develop.
12. Answer: 1.
Cough syrups and cold medicines are not to be given,
because they may dry and thicken secretions.
During a croup attack, the child can be taken to a cool
basement or garage. Acetaminophen is used if a fever
develops. Adequate hydration of 500 to 1000 mL of fluids
daily is important for thinning secretions.
13. Answers: 1, 4, 5, and 6.
Medications recommended for treatment of heart failure
include diuretics, cardiac glycosides such as digoxin
(Lanoxin), PDE inhibitors, and ACE inhibitors. Clients in heart
failure do not need anticoagulants or anticholinergics.
14. Answer: 1.
The transition point for switching to the forward-facing
position is defined by the manufacturer of the convertible car
safety seat, but it is generally at a body weight of 9 kg (20 lb)
and an age of 1 year. Options 2, 3, and 4 are incorrect.
15. Answer: 4.
If herpetic genital lesions are present at the time of delivery,
a cesarean delivery will be necessary to reduce the risk of
infecting the neonate. In the absence of herpetic genital
lesions, a vaginal delivery may be indicated, unless there are
other reasons for performing a cesarean delivery. Maternal
isolation is not necessary, but potentially exposed neonates
should be cultured on the day of delivery.
16. Answers: 1, 2, 3, and 6.
Clients with cardiac, respiratory, renal, or liver diseases and
older and very young clients cannot tolerate an excessive fluid
volume. The risk of fluid (circulatory) overload exists with
these clients
17. Answer: 4.
Generally there are only two instances in which the informed
consent of an adult client is not needed. One instance is when
an emergency is present and delaying treatment for the
purpose of obtaining informed consent would result in injury
or death to the client. The second instance is when the client
waives the right to give informed consent. Options 1, 2, and 3
are inappropriate.
18. Answer: 2.
Toys for the toddler must be strong, safe, and too large to
swallow or place in the ear or nose. Toddlers need supervision
at all times. Push-pull toys, large balls, large crayons, trucks,
and dolls are some appropriate toys. A puzzle with large
pieces only may be appropriate. A farm set and a golf set
may contain items that the child could swallow.
19. Answers: 2, 5, and 6.
Anatomical changes to the eye affect the individual’s visual
ability, which leads to potential problems with activities of
daily living. Light adaptation and visual fields are reduced.
Respiratory rates are usually unchanged. The heart rate
decreases, and the heart valves thicken. Age-related changes
that affect the urinary tract increase an older client’s
susceptibility to urinary tract infections. Short-term memory
may decline with age, but long-term memory is usually
maintained. Changes in sleep patterns are consistent,
age-related changes. Older persons experience an increased
incidence of awakening after sleep onset.
20. Answer: 1
Coping mechanisms are behaviors that are used to decreased
stress and anxiety. In response to a death, ineffective coping
is manifested by an extreme behavior that in some instances
may be harmful to the individual, physically, psychologically,
or both. Option 1 is indicative of a behavior that identifies an
ineffective coping behavior as part of the grieving process.
The remaining options identify effective coping behaviors.
NCLEX SATA 5
1. The nurse notes that a client is quite suspicious
during an assessment interview and believes that her
family is under investigation by the CIA. What would
the appropriate nursing interventions be with this
client? Select all that apply:
1. Use active listening skills to seek information from the
client.
2. Encourage the client to describe the problem as she sees it.
3. Ask the client to tell you exactly what she thinks is
happening.
4. Tell the client that she is delusional and you can help her.
5. Explain to the client that most people are not investigated
by the CIA.
6. Reassure the client that you are not with the CIA.
2. Which nursing interventions will assist in reducing
pressure points that may lead to pressure ulcers?
Check all that apply:
1. Position the client directly on the trochanter when side
lying.
2. Avoid use of donut type devices.
3. Massage bony prominences.
4. Elevate the HOB no more than 30 degrees when possible.
5. When the client is side lying, use the 30 degree lateral
inclined position.
6. Avoid uninterrupted sitting in a chair or wheelchair.
3. The nurse is evaluating a client recently diagnosed
with primary open angle glaucoma (POAG). What will
an important nursing action be? Select all that apply:
1. Review meds the client is currently on to determine
whether any of them cause an increased intraocular pressure
as a side effect.
2. Determine whether the client has any sudden loss of vision
accompanied by pain.
3. Discuss with the client the importance of controlling blood
pressure to decrease the potential loss of peripheral vision.
4. Instruct the client to take analgesics as soon as any
discomfort occurs in the eye and to notify clinic if pain is not
relieved.
5. Have the client demonstrate the use of eye drops.
6. Assess the client for chronic diseases such as diabetes.
4. A nurse understands that a patient may experience
pain during peritoneal dialysis because of which of the
following? Select all that apply:
1. Warming the dialysate
2. Too rapid installation
3. Infiltration of the solution into the bloodstream
4. Accumulation of dialysate solution under the diaphragm
5. Too rapid outflow of the dialysate.
5. The nurse is evaluating a client’s response to
hemodialysis. Which lab results will indicate the
dialysis was effective? Select all that apply:
1. Serum potassium level decreases from 5.4 to 4.6 mEq/L
2. Cr decreases from 1.6 to 0.8 mg/dL
3.Hgb increases from 10-12 g/dL
4. WBC increase from 5000 to 8000/mm^3
5. BUN decreases from 110 to 90 mg/dL
6. The nurse understands that the following clinical
findings are indications for dialysis. Select all that
apply:
1. Volume overload
2. BUN 18 mg/dL
3. K 5.2 mEq/L
4. Decreased creatinine clearance.
5. Metabolic acidosis
6. Cr 5.0 mg/dL
7. The nurse is assessing a client who had a fractured
femur repaired with an external fixator device. Which
assessment finding would cause the nurse concern
regarding the development of compartment syndrome?
Select all that apply:
1. Decrease in pulse rate in affected leg.
2. Paresthesia distal to area of injury.
3. Toes on affected leg cool to touch and edematous.
4. Complaints that pins are hurting.
5. Complaints of leg pain unrelieved by analgesics or
repositioning.
6. Client angry and calling loudly to the nurse every ten
minutes.
8. The nurse is preparing discharge for a patient with
GERD. What would be important for the nurse to
include in this teaching plan? Select all that apply:
1. Elevate the HOB.
2. Decrease intake of caffeine.
3. Discuss strategies for weight loss if overweight.
4. Increase fluid intake with meals.
5. Take ranitidine (Zantac) at hs.
6. Eat a bedtime snack of milk and protein.
9. The nurse is preparing a client for cardiac
catheterization. Which nursing interventions are
necessary in preparing the client for this procedure.
Select all that apply:
1. Verify consent has been signed.
2. Explain procedure to client.
3. Provide clear liquid, no caffeine diet.
4. Evaluate peripheral pulses.
5. Obtain a 12 lead ECG
6. Obtain history of shellfish allergy.
10. The nurse has been assigned a group of cardiac
clients. What would be the most important information
for the nurse to check on the initial evaluation of each
client? Select all that apply:
1. Presence of cardiac pain.
2. Medications taken before hospitalizations.
3. Presence of jugular vein distention.
4. Heart sounds and apical rate.
5. Presence of diaphoresis.
6. History of difficulty breathing.
11. The nurse is teaching a client about home care and
treatment of venous stasis ulcers in his leg. What
should be included in the nurse’s instructions? Select
all that apply:
1. Dressings do not need to be changed frequently because
there is minimal drainage.
2. Healing will be facilitated by wearing leg compression
devices.
3. When the client is in sitting position, he should keep his
legs elevated.
4. Avoid standing for long periods of time.
5. Cool packs can be applied to the ulcers to decrease
inflammation.
6. Soak the affected extremity in warm water every evening.
12. A nurse knows the clinical manifestations of a client
with Addison’s disease include which of the following?
Select all that apply:
1. Nausea
2. Hypothermia
3. Hypertension
4. Hyperpigmentation
5. Hypotension
6. Hypernatremia
13. A licensed practical nurse is attending an agency
orientation meeting about the nursing model of
practice implemented in the facility. The nurse is told
that the nursing model is a team nursing approach. The
nurse understands that which of the following is a
characteristic of this type of nursing model of practice?
1. A task approach method is used to provide care to clients.
2. Managed care concepts and tools are used when providing
client care.
3. Nursing staff are led by a nurse when providing care to a
group of clients.
4. A single registered nurse is responsible for providing
nursing care to a group of clients.
14. A licensed practical nurse is planning the client
assignments for the day. Which of the following is the
most appropriate assignment for the nursing assistant?
1. A client who requires wound irrigation
2. A client who requires frequent ambulation
3. A client who is receiving continuous tube feedings
4. A client who requires frequent vital signs after a cardiac
catheterization
15. A male client who has heart failure receives an
additional dose of bumetanide as prescribed 4 hours
after the daily dose. The nurse assesses him 15
minutes after administering the medication and
reminds him to save all urine in the bathroom. Thirty
minutes later the nurse finds the client on the floor,
unresponsive, and bleeding from a laceration.
Determine the issues that support the client’s
malpractice claim. Select all that apply.
1. Failure to replace body fluids
2. Increased risk of hypotension
3. Failure to teach the client adequately
4. Increased need to protect the client
5. Excessive bumetanide administration
6. Lack of follow-up nursing actions
Answers and Rationale
1. Answers: 1,2,3.
The client is displaying paranoid behaviours, which Addison’s disease is due to hypofunctioning of the adrenal
necessitates a matter of fact approach that is nonjudgmental cortex. The clinical manifestations have a very slow onset,
and accepting the client’s statements and show the nurses and skin hyperpigmentation is a classic sign. Fatigue, nausea,
willingness to actively listen. The last three do not contribute weight loss, hypotension, hyponatremia, and hyperkalemia
to a therapeutic nurse client relationship. are other findings associated with the condition.
2. Answers: 2, 4, 5 ,6. 13. Answer: 3.
Elevating the head of the bed to 30 degrees or less will In team nursing, nursing personnel are led by a nurse when
decrease the chance of ulcer development from shearing providing care to a group of clients. Option 1 identifies
forces. When placing the client in a side lying position, use functional nursing. Option 2 identifies a component of case
the 30 degree lateral inclined position. Do not place the client management. Option 4 identifies primary nursing.
on their trochanter. Avoid donuts which promote ischemia. 14. Answer: 2.
Don’t massage bony prominences as this causes capillary The nurse must determine the most appropriate assignment
break down and injury leading to pressure ulcers. on the basis of the skills of the staff member and the needs of
3. Answers: 1, 5, 6. the client. In this case, the most appropriate assignment for a
Medications must be evaluated in terms of their potential for nursing assistant would be to care for the client who requires
increasing the intraocular pressure. Ophthalmic drops are frequent ambulation. The nursing assistant is skilled in this
often prescribed for glaucoma and clients should know how to task. The
administer them correctly. Diabetes is a risk factor and its client who had a cardiac catheterization will require specific
mgmt is important in helping slow POAG. An increase in monitoring in addition to that of the vital signs. Wound
intraocular pressure could cause further damage to a patient irrigations and tube feedings are not performed by unlicensed
with POAG. The questions states the client is already personnel.
diagnosed, POAG is painless and not correlated to BP. 15. Answers: 2, 3, 4, and 6.
4. Answers: 2,4. To prove malpractice against a nurse, the plaintiff must prove
Rapid outflow doesn’t cause pain, warming helps with that the nurse owed a duty to the client, that the nurse
discomfort and the dialysate does not infiltrate the circulation. breached the duty, and that as a result harm was caused to
5. Answers: 1, 2, 5. person or property. The client has an increased risk of
Primary action of hemodialysis is to clear nitrogenous waste hypotension (option 2) because hypotension is a common
products. adverse effect of bumetanide, this is the second dose within 4
6. Answers: 1, 3, 5, 6. hours, and the client has heart failure. The client can prove
Indications for dialysis include volume overload, weight gain, that the nurse did not protect him by failing to provide
hyperkalemia, metabolic acidosis, and rising BUN (normally adequate teaching and perform correct and timely nursing
10-20 mg/dL) and Cr (normally 0.5-1.5 mg/dL) levels, along interventions (options 3, 4, and 6) after administering the
with decreased urinary creatinine clearance. The K level is bumetanide. After the first 15-minute check, the nurse should
hyperkalemic, the BUN is normal. continue increased client monitoring to ensure client
7. Answers: 2, 3, 5. compliance with safety measures. Replacing fluid volume is
Paresthesia, edema, and leg pain unrelieved by analgesics are not the issue; furthermore, the goal of therapy is to reduce
classic indicators of the development of compartmental total body fluid. No data indicate that the dose of bumetanide,
syndrome. With a femur fracture the will be edema, a a loop diuretic, was excessive. However, because this
decrease in rate is not an indication of pressure, a decrease in medication can cause hypotension, especially after a repeat
pulse strength is. Anger can be due to immobility, and the dose, the nurse should instruct the client to remain in bed and
pins do not usually cause pain, but this may be a sign of provide him with a urinal. It may be difficult for the client to
infection. prove that the second dose of bumetanide caused the injury.
8. Answers: 1, 2, 3, 5.
This will all help neutralize stomach acid. Drinking lots with
meals and eating before bed will exacerbate the problem.
9. Answers: 1, 2, 5, and 6.
In cardiac catheterization contrast dye is injected into the
coronary artery and provides info on patency. Informed
consent must be signed prior to any invasive procedure. The
physician is responsible for explaining the procedure, the
nurse can reinforce. Patient would be NPO 6-18 hours prior.
An ECG would be done, but measures electrical not blood
flow. Peripheral pulses is important afterwards. Shellfish is an
indicator of an allergy to the medium injected.
10. Answers: 1, 3, 4, and 5.
A focussed cardiac assessment is directed towards assessing
physiologic symptoms (cardiac pain, JVD, heart sounds and
rate, and presence of diaphoresis) that provide immediate
information regarding the clients condition, which is
appropriate for the nurse to do at the beginning of each shift.
After the physiological parameters have been evaluated the
nurse can determine history of SOB and meds.
11. Answers: 2, 3, and 4.
Healing of venous stasis ulcers in dependent on relieving the
venous congestion in the extremity. Compression devices and
elevation of the extremity are the most effective methods.
The client should avoid standing for long periods since this
increases venous stasis. Moist cool and/or warm packs are
NOT used, but moist environment dressings are utilized.
Dressings need to be changed as frequently as necessary
because there may be excessive drainage.
12. Answers: 1, 4, and 5.