Prep | NCLEX SATA Questions with Rationales
Which finding indicates Stage 1 pressure injury? - ANSWER-Non-blanch able redness
Which patient statement represents subjective data? - ANSWER-I feel dizzy when I stand up.
What position is a patient in when leaning forward with hands on knees to breathe? - ANSWER-Tripod
Which patient is at highest risk for falls? - ANSWER-Patient with orthostatic hypotension
What is the nurse's first action when assessing the abdomen? - ANSWER-Inspection
Which test evaluates distance vision? - ANSWER-Snellen chart
Which finding requires immediate follow-up? - ANSWER-Irregular pulse
What priority intervention should a patient with dysphagia have? - ANSWER-Elevate HOB
Which is a modifiable risk factor for CAD? - ANSWER-Smoking
What condition is indicated by a patient reporting 'ringing in my ears'? - ANSWER-Tinnitus
What does a murmur indicate? - ANSWER-Extra heart sound
Which diet teaching is correct for heart disease? - ANSWER-Low cholesterol
What type of headache is described as a 'tight band' around the head? - ANSWER-Tension headache
Which finding suggests melanoma? - ANSWER-Diameter >6 mm
What is the correct action for assessing carotid arteries? - ANSWER-Auscultate first
A patient with PAD will likely report what symptom? - ANSWER-Pain when walking
Which sound is expected with excess abdominal gas? - ANSWER-Tympany
What is the best way to assess an irregular pulse? - ANSWER-1 full minute
Which indicates acute infection in lymph nodes? - ANSWER-Enlarged and tender
What is it called when a patient has difficulty breathing when lying flat? - ANSWER-Orthopnea
Which are characteristics of migraine headaches? - ANSWER-Aura, Relief in dark room, Long-lasting
pain
Which are included in eye assessment? - ANSWER-Visual acuity, External structures, Visual fields
Which are standard precautions? - ANSWER-Hand hygiene, Gloves when needed, Apply to all patients