NCLEX SATA Questions

1. A client who is 29 weeks pregnant comes to the labor and delivery unit. She states that she’s having contractions every 8 minutes. The client is also 3 cm dilated. Which medications can the nurse expect to administer? Select all that apply.

1. Folic acid (Folvite)
2. Terbutaline (Brethine)
3. Betamethasone
4. Rho (D) immune globulin (Rhogam)
5. I.V. fluids
6. Meperidine (Demerol)

Answer: 2, 3, 5

2. Which of these interventions would be most appropriate when performing glucose testing with One-Touch or Accu-Check? Select all that apply.

1. Dilate the capillaries by applying a coo, moist compress to the area for about 3 minutes
2. Wipe the puncture site with an alcohol sponge, and dry it thoroughly with a gauze pad.
3. Make the puncture on the end of the fingertip.
4. After puncturing finger, squeeze site to facilitate blood flow.
5. Touch a drop of blood to the reagent patch on the strip making sure to cover the entire patch.
6. Leave the blood on the strip for exactly 30 seconds.

Answer: 2, 5

3. The nurse is evaluating a client who is 34 weeks pregnant for premature rupture of the membranes (PROM). Which findings indicate that PROM has occurred? Select all that apply.

1. Fernlike pattern when vaginal fluid is placed on a glass slide and allowed to dry
2. Acidic pH of fluid when tested with nitrazine paper
3. Presence of amniotic fluid in the vagina
4. Cervical dilation of 6 cm
5. Alkaline pH of fluid when tested with nitrazine paper
6. Contractions occurring every 5 minutes

Answer:  1, 3, 5

4.Which of these would be the most appropriate to assign to the LPN? Select all that apply. A client who:

1. has the diagnosis of myasthenia gravis
2. is receiving chemotherapy
3. is a new admission with chest pain
4. is being discharged and needs new diabetic teaching
5. is in Buck’s traction

Answer: 1, 5

5. What information should the nurse include when teaching postcircumcision care to parents of a neonate before discharge from the hospital?
Select all that apply.

1. The infant must void before being discharged home.
2. Petroleum jelly should be applied to the glans of the penis with each diaper change.
3. The infant can take tub baths while the circumcision heals.
4. Any blood noted on the front of the diaper should be reported.
5. The circumcision will require care for 2 to 4 days after discharge.

Answer: 1, 2, 5

6. To promote client safety, which pieces of equipment should be readily available at the bedside when client has a seizure disorder? Select all that apply.

1. oral airway
2.nasogastric tube
3. suction
4. ventilator
5. tracheostomy set

Answer: 1,3

7. A 28-year-old client is admitted with inflammatory bowel syndrome (Crohn’s disease). Which therapies should the nurse expect to be part of the care plan? Select all that apply.

1. Lactulose therapy
2. High-fiber diet
3. High-protein milkshakes
4. Corticosteroid therapy
5. Antidiarrheal medications

Answer: 4, 5

8. The nurse is caring for a client who has neisseria meningitis. Which of the following infection control precautions should the nurse implement? Select all that apply.

1. Wear gloves when entering client’s room
2. Request client’s visitors to wear a gown when in the room.
3. Wear a mask when working within 3 feet of the client.
4. Keep visitors 3 feet from infected client
5. Limit movement of the client from the room.
6. If the client must leave the room, have him wear a surgical mask, if possible

Answer 3,4,5,6

9. The nurse is assisting in the discharge planning for a client with alcoholism. Which of the following should be included in the discharge plan? Select all that apply:
1. Strongly encourage participation in Alcoholics Anonymous (AA).
2. Provide nutritional information and counseling.
3. Establish an exercise program.
4. Discuss relapse prevention.
5. Have the client introduce himself slowly to people from his former lifestyle.

Answer: 1, 2, 3, 4

10. A client with a history of heat failure and hypertensio is taking a variety of medications at home. In teaching the client about the blood pressure lowering efects of the medications, which of the client’ medicaitons will she inclued in the discussion? Select all that apply.

1. Hydrochlorothiazide (HCTZ)
2. Simvastatin
3. Lisinopril
4. Nizatidine
5. Atenolol

Answer 1,3,5

11. The nurse receives a change-of-shift report for a 76-year-old client who had a total hip replacement. The client is not oriented to time, place, or person and is attempting to get out of bed and pull out an I.V. line that’s supplying hydration and antibiotics. The client has a vest restraint and bilateral soft wrist restraints. Which action by the nurse would be appropriate? Select all that apply.

1. Assess and document the behavior that requires continued use of restraints.
2. Tie the restraints in quick-release knots.
3. Tie the restraints to the side rails of the bed.
4. Ask the client if he needs to go to the bathroom and provide range-of-motion exercises every 2 hours.
5. Position the vest restraints so that the straps are crossed in the back.

Answer: 1, 2, 4

12. The nurse is performing a Denver Developmental Screening Test II on a 4 1/2-year-old child. What behaviors should the nurse expect the child to demonstrate? Select all that apply:

1. He balances on each foot for at least 6 seconds.
2. He copies a square using straight lines and square corners.
3. He prepares his own cereal without help.
4. He copies a circle that’s closed or very nearly closed.
5. He speaks clearly.
6. He draws a person with at least three body parts.

Answer: 3, 4, 5, 6

13. The nurse is caring for a 45-year-old married woman who has undergone hemicolectomy for colon cancer. The woman has two children. Which concepts about families should the nurse keep in mind when providing care for this client? Select all that apply.

1. Illness in one family member can affect all members.
2. Family roles don’t change because of illness.
3. A family member may have more than one role at a time in a family.
4. Children typically aren’t affected by adult illness.
5. The effects of an illness on a family depend on the stage of the family’s life cycle.
6. Changes in sleeping and eating patterns may be signs of stress in a family.

Answer: 1, 3, 5, 6

14. A client is receiving chlordiazepoxide (Librium) to control the symptoms of alcohol withdrawal. The chlordiazepoxide has been ordered as needed. Which symptom may indicate the need for an additional dose of this medication? Select all that apply.

1. Tachycardia
2. Mood swings
3. Elevated blood pressure and temperature
4. Piloerection
5. Tremors
6. Increasing anxiety

Answer: 1, 3, 5, 6

15. The nurse is preparing a female client with tonic-clonic seizure disorder for discharge. Which instructions should the nurse include about phenytoin (Dilantin)?Select all that apply.

1. “Monitor for skin rash.”
2. “Maintain adequate amounts of fluid and fiber in the diet.”
3. “Perform good oral hygiene, including daily brushing and flossing.”
4. “Receive necessary periodic blood work.”
5. “Report to the physician any problems with walking, coordination, slurred speech, or nausea.”
6. “Feel safe about taking this drug, even during pregnancy.”

Answer:  1, 3, 4, 5

16. The nurse is assisting in the discharge planning for a client with alcoholism. Which of the following should be included in the discharge plan? Select all that apply.

1. Strongly encourage participation in Alcoholics Anonymous (AA).
2. Provide nutritional information and counseling.
3. Establish an exercise program.
4. Discuss relapse prevention.
5. Have the client introduce himself slowly to people from his former lifestyle.

Answer: 1, 2, 3, 4

17. A woman who is 15 weeks pregnant comes to the clinic for amniocentesis. The nurse knows that this test can be used to identify which characteristics or problems? Select all that apply.

1. Fetal lung maturity
2. Gestational diabetes
3. Chromosomal defects
4. Neural tube defects
5. Polyhydramnios
6. Sex of the fetus

Answer: 3, 4, 6

18. The nurse is explaining the Bill of Rights for psychiatric patients to a client who has voluntarily sought admission to an inpatient psychiatric facility. Which of the following rights should the nurse include in the discussion? Select all that apply.

1. Right to select health care team members
2. Right to refuse treatment
3. Right to a written treatment plan
4. Right to obtain disability
5. Right to confidentiality
6. Right to personal mail

Answer: 2, 3, 5, 6

19. A client is prescribed lisinopril (Zestril) for treatment of hypertension.  He asks a nurse about possible adverse effects. The nurse should teach him about which of the following  common adverse effects of angiotensin converting enzyme (ACE) inhibitors? Select all that apply.

1. Constipation
2. Dizziness
3. Headache
4. Hyperglycemia
5. Hypotension
6. Impotence

Answer: 2,3,5,6

20.  A client who is 41 weeks pregnant is about to undergo a biophysical profile (BPP) to evaluate her fetus’s well-being. The nurse knows that which components are included in a BPP? Select all that apply:

1. Fetal tone
2. Fetal breathing movements
3. Femur length
4. Amniotic fluid volume
5. Biparietal diameter
6. Crown-rump length

Answer: 1,2,4