NCLEX SATA 1-5. A Complete and Comprehensive Select All That Apply Questions and Answers.

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. Monitor deep tendon reflexes hourly
5. Reposition the client to his or her side. 6. Monitor I and O’s hourly
16. The nurse is caring for a hospitalized client who has 7. Notify the physician if urinary output is less than 30 ml per
chronic renal failure. Which of the following nursing hour.
diagnoses are most appropriate for this client? Select 23. When interpreting an ECG, the nurse would keep in
all that apply. mind which of the following about the P wave? Select
1. Excess Fluid Volume all that apply.
2. Imbalanced Nutrition; Less than Body Requirements 1. Reflects electrical impulse beginning at the SA node
3. Activity Intolerance 2. Indicated electrical impulse beginning at the AV node
4. Impaired Gas Exchange 3. Reflects atrial muscle depolarization
5. Pain. 4. Identifies ventricular muscle depolarization
17. The nurse is assessing a child diagnosed with a 5. Has duration of normally 0.11 seconds or less.
brain tumor. Which of the following signs and 24. When caring for a client with a central venous line,
symptoms would the nurse expect the child to which of the following nursing actions should be
demonstrate? Select all that apply. implemented in the plan of care for chemotherapy
1. Head tilt administration? Select all that apply.
2. Vomiting 1. Verify patency of the line by the presence of a blood return
3. Polydipsia at regular intervals.
4. Lethargy 2. Inspect the insertion site for swelling, erythema, or
5. Increased appetite drainage.
6. Increased pulse 3. Administer a cytotoxic agent to keep the regimen on
18. The nurse is caring for a client with a T5 complete schedule even if blood return is not present.
spinal cord injury. Upon assessment, the nurse notes 4. If unable to aspirate blood, reposition the client and
flushed skin, diaphoresis above the T5, and a blood encourage the client to cough.
pressure of 162/96. The client reports a severe, 5. Contact the health care provider about verifying placement
pounding headache. Which of the following nursing if the status is questionable.
interventions would be appropriate for this client? 25. To assist an adult client to sleep better the nurse
Select all that apply. recommends which of the following? (Select all that
1. Elevate the HOB to 90 degrees apply.)
2. Loosen constrictive clothing 1. Drinking a glass of wine just before retiring to bed
3. Use a fan to reduce diaphoresis 2. Eating a large meal 1 hour before bedtime
4. Assess for bladder distention and bowel impaction 3. Consuming a small glass of warm milk at bedtime
5. Administer antihypertensive medication 4. Performing mild exercises 30 minutes before going to bed
6. Place the client in a supine position with legs elevated 26. The nurse recognizes that a client is experiencing
19. The nurse is evaluating the discharge teaching for a insomnia when the client reports (select all that apply):
client who has an ileal conduit. Which of the following 1. Extended time to fall asleep
statements indicates that the client has correctly 2. Falling asleep at inappropriate times
understood the teaching? Select all that apply. 3. Difficulty staying asleep
1. “If I limit my fluid intake I will not have to empty my 4. Feeling tired after a night’s sleep
ostomy pouch as often.” 27. The nurse teaches the mother of a newborn that in
2. “I can place an aspirin tablet in my pouch to decrease order to prevent sudden infant death syndrome (SIDS)
odor.” the best position to place the baby after nursing is
3. “I can usually keep my ostomy pouch on for 3 to 7 days (select all that apply):
before changing it.” 1. Prone
4. “I must use a skin barrier to protect my skin from urine.” 2. Side-lying
5. “I should empty my ostomy pouch of urine when it is full.” 3. Supine
20. A nurse is assisting in performing an assessment on 4. Fowler’s
a client who suspects that she is pregnant and is 28. A client has a diagnosis of primary insomnia. Before
checking the client for probable signs of assessing this client, the nurse recalls the numerous
pregnancy. Select all probable signs of pregnancy. causes of this disorder. Select all that apply:
1. Uterine enlargement 1. Chronic stress
2. Fetal heart rate detected by nonelectric device 2. Severe anxiety
3. Outline of the fetus via radiography or ultrasound 3. Generalized pain
4. Chadwick’s sign 4. Excessive caffeine
5. Braxton Hicks contractions 5. Chronic depression
6. Ballottement 6. Environmental noise
21. A nurse is monitoring a pregnant client with 29. Select all that apply to the use of barbiturates in
pregnancy induced hypertension who is at risk for treating insomnia:
Preeclampsia. The nurse checks the client for which 1. Barbiturates deprive people of NREM sleep
specific signs of Preeclampsia (select all that apply)? 2. Barbiturates deprive people of REM sleep
1. Elevated blood pressure 3. When the barbiturates are discontinued, the NREM sleep
2. Negative urinary protein increases.
3. Facial edema 4. When the barbiturates are discontinued, the REM sleep
4. Increased respirations increases.
22. A nurse is caring for a pregnant client with severe 5. Nightmares are often an adverse effect when discontinuing
preeclampsia who is receiving IV magnesium sulfate. barbiturates.
Select all nursing interventions that apply in the care 30. Select all that apply that is appropriate when there
for the client. is a benzodiazepine overdose:
1. Monitor maternal vital signs every 2 hours 1. Administration of syrup of ipecac
2. Notify the physician if respirations are less than 18 per 2. Gastric lavage
minute. 3. Activated charcoal and a saline cathartic
3. Monitor renal function and cardiac function closely 4. Hemodialysis
4. Keep calcium gluconate on hand in case of a magnesium 5. Administration of Flumazenil
sulfate overdose