SATA NCLEX SAUNDERS REVIEW
QUESTIONS AND ANSWERS| GRADED A
A client is monitoring a client receiving theophylline (Theo-24) to treat symptoms
of chronic obstructive pulmonary disease (COPD). Which adverse effects require
immediate consultation with the health care provider? Correct answerTheophylline
is a bronchodilator. Irregular heartbeats and seizures are signs of toxicity and
require immediate health care provider notification. Anxiety and insomnia are
common side effects and do not require immediate action. Diarrhea is not
associated with theophylline toxicity.
A NURS is preparing a list of cast care instructions for a client who just had a
plaster cast applied to his right forearm. Which instructions should the NURS
include on the list? Correct answerKeep the cast and extremity elevated.
The cast needs to be kept clean and dry.
Allow the wet cast 24 to 72 hours to dry.
A NURS is preparing a list of cast care instructions for a client who just had a
plaster cast applied to his right forearm. Which instructions should the NURS
include on the list? Correct answerSymptom control during periods of emotional
stress
Normal white blood cell counts, platelet, and neutrophil counts
Radiological findings that show nonprogression of joint degeneration
An increased range of motion in the affected joints 3 months into therapy
A NURS is providing client teaching regarding glaucoma. Which of the following
are important to include in the teaching plan? Correct answerBe sure to report
halos of light or increased eye pain to your health care provider.
Follow a low-sodium, minimal-caffeine diet with plenty of fiber.
A client who has undergone a colostomy several days ago is reluctant to leave the
hospital and has not yet looked at the ostomy site. Which measures are most likely
to promote coping? Correct answerA member of the local ostomy club will be able
to provide realistic encouragement. The enterostomal NURS specialist will be able
to provide helpful information to the client. Asking the client to assist with tasks
may encourage the client to take on more advanced skills and become more
adjusted to the ostomy. Reminding the client about the responsibility for caring for
,the colostomy and telling the client that infection is a major complication (which is
incorrect) will alarm the client.
Rifabutin (Mycobutin) is prescribed for a client with active Mycobacterium avium
complex (MAC) disease and tuberculosis. The NURS monitors for which side
effects of the medication? Correct answerSigns of hepatitis
Flu-like syndrome
Low neutrophil count
Ocular pain or blurred vision
A NURS in a medical unit is caring for a client with heart failure. The client
suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the NURS
suspects pulmonary edema. The NURS immediately notifies the registered NURS
and expects which interventions to be prescribed? Correct answerAdministering
oxygen
Inserting a Foley catheter
Administering furosemide (Lasix)
Administering morphine sulfate intravenously
A client with coronary artery disease complains of substernal chest pain. After
checking the client's heart rate and blood pressure, a NURS administers
nitroglycerin, 0.4 mg, sublingually. After 5 minutes, the client states, "My chest
still hurts." Select the appropriate actions that the NURS should take. Correct
answerAssess the client's pain level.
Check the client's blood pressure.
Administer a second nitroglycerin, 0.4 mg, sublingually.
Contact the registered NURS.
The NURS monitoring a client receiving peritoneal dialysis notes that the client's
outflow is less than the inflow. The NURS should take which actions? Correct
answerCheck the level of the drainage bag.
Reposition the client to his or her side.
Place the client in good body alignment.
Check the peritoneal dialysis system for kinks.
The NURS is preparing a teaching plan for a client who is undergoing cataract
extraction with intraocular implant. Which home care measures will the NURS
include in the plan? Correct answerTo avoid activities that require bending over
To place an eye shield on the surgical eye at bedtime
To contact the surgeon if a decrease in visual acuity occurs
,To take acetaminophen (Tylenol) for minor eye discomfort
The NURS is preparing to administer eye drops. Select the interventions that the
NURS takes to administer the drops Correct answerWash hands.
Put on gloves.
Place the drop in the conjunctival sac.
Pull the lower lid down against the cheek bone.
A client is receiving meperidine hydrochloride (Demerol) for pain. Which of the
following are side effects of this medication Correct answerHypotension
Tremors
Drowsiness
Which interventions would apply in the care of a client at high risk for an allergic
response to a latex allergy. Correct answerUse non-latex gloves.
Use medications from glass ampules
Keep a latex-safe supply cart available in the client's area.
Do not puncture rubber stoppers with needles
Ketoconazole is prescribed for a client with a diagnosis of candidiasis. Select the
interventions that the NURS includes when administering this medication Correct
answerMonitor hepatic and liver function studies.
Instruct the client to avoid alcohol.
Instruct the client to avoid exposure to the sun.
A client with human immunodeficiency virus is taking nevirapine (Viramune). The
NURS should monitor for which adverse effects of the medication? Correct
answerHepatotoxicity
Rash
The NURS in the mental health unit reviews the therapeutic and nontherapeutic
communication techniques with a nursing student. Which of the following are
therapeutic communication techniques? Correct answerRestating
Listening
Maintaining neutral responses
Providing acknowledgment and feedback
, Which nursing interventions are appropriate for a hospitalized client with mania
who is exhibiting manipulative behavior? Correct answerAssist the client in
developing means of setting limits on personal behavior.
Follow through about the consequences of behavior in a nonpunitive manner.
Be clear with the client regarding the consequences of exceeding limits set
regarding behavior.
Communicate expected behaviors to the client.
Which of the following are appropriate interventions for caring for the client in
alcohol withdrawal Correct answerMonitor vital signs.
Provide a safe environment.
Address hallucinations therapeutically.
Provide reality orientation as appropriate.
A NURS is preparing to care for a dying client, and several family members are at
the client's bedside. Which therapeutic techniques should the NURS use when
communicating with the family. Correct answerExtend touch and hold the client's
or family member's hand if appropriate.
Be honest and truthful and let the client and family know that you will not abandon
them
Encourage expression of feelings, concerns, and fears.
A hospitalized client is started on phenelzine sulfate (Nardil) for the treatment of
depression. The NURS instructs the client to avoid consuming which foods while
taking this medication? Correct answerFigs
Yogurt
Aged cheese
A client enters the emergency room confused, twitching, and having seizures. His
family states he recently was placed on corticosteroids for arthritis and was feeling
better and exercising daily. Upon assessment, 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. Correct answerMonitor intake and output.
Monitor the vital signs.
Monitor the electrolyte levels.
Increase water intake orally.
Provide a sodium-reduced diet.
QUESTIONS AND ANSWERS| GRADED A
A client is monitoring a client receiving theophylline (Theo-24) to treat symptoms
of chronic obstructive pulmonary disease (COPD). Which adverse effects require
immediate consultation with the health care provider? Correct answerTheophylline
is a bronchodilator. Irregular heartbeats and seizures are signs of toxicity and
require immediate health care provider notification. Anxiety and insomnia are
common side effects and do not require immediate action. Diarrhea is not
associated with theophylline toxicity.
A NURS is preparing a list of cast care instructions for a client who just had a
plaster cast applied to his right forearm. Which instructions should the NURS
include on the list? Correct answerKeep the cast and extremity elevated.
The cast needs to be kept clean and dry.
Allow the wet cast 24 to 72 hours to dry.
A NURS is preparing a list of cast care instructions for a client who just had a
plaster cast applied to his right forearm. Which instructions should the NURS
include on the list? Correct answerSymptom control during periods of emotional
stress
Normal white blood cell counts, platelet, and neutrophil counts
Radiological findings that show nonprogression of joint degeneration
An increased range of motion in the affected joints 3 months into therapy
A NURS is providing client teaching regarding glaucoma. Which of the following
are important to include in the teaching plan? Correct answerBe sure to report
halos of light or increased eye pain to your health care provider.
Follow a low-sodium, minimal-caffeine diet with plenty of fiber.
A client who has undergone a colostomy several days ago is reluctant to leave the
hospital and has not yet looked at the ostomy site. Which measures are most likely
to promote coping? Correct answerA member of the local ostomy club will be able
to provide realistic encouragement. The enterostomal NURS specialist will be able
to provide helpful information to the client. Asking the client to assist with tasks
may encourage the client to take on more advanced skills and become more
adjusted to the ostomy. Reminding the client about the responsibility for caring for
,the colostomy and telling the client that infection is a major complication (which is
incorrect) will alarm the client.
Rifabutin (Mycobutin) is prescribed for a client with active Mycobacterium avium
complex (MAC) disease and tuberculosis. The NURS monitors for which side
effects of the medication? Correct answerSigns of hepatitis
Flu-like syndrome
Low neutrophil count
Ocular pain or blurred vision
A NURS in a medical unit is caring for a client with heart failure. The client
suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the NURS
suspects pulmonary edema. The NURS immediately notifies the registered NURS
and expects which interventions to be prescribed? Correct answerAdministering
oxygen
Inserting a Foley catheter
Administering furosemide (Lasix)
Administering morphine sulfate intravenously
A client with coronary artery disease complains of substernal chest pain. After
checking the client's heart rate and blood pressure, a NURS administers
nitroglycerin, 0.4 mg, sublingually. After 5 minutes, the client states, "My chest
still hurts." Select the appropriate actions that the NURS should take. Correct
answerAssess the client's pain level.
Check the client's blood pressure.
Administer a second nitroglycerin, 0.4 mg, sublingually.
Contact the registered NURS.
The NURS monitoring a client receiving peritoneal dialysis notes that the client's
outflow is less than the inflow. The NURS should take which actions? Correct
answerCheck the level of the drainage bag.
Reposition the client to his or her side.
Place the client in good body alignment.
Check the peritoneal dialysis system for kinks.
The NURS is preparing a teaching plan for a client who is undergoing cataract
extraction with intraocular implant. Which home care measures will the NURS
include in the plan? Correct answerTo avoid activities that require bending over
To place an eye shield on the surgical eye at bedtime
To contact the surgeon if a decrease in visual acuity occurs
,To take acetaminophen (Tylenol) for minor eye discomfort
The NURS is preparing to administer eye drops. Select the interventions that the
NURS takes to administer the drops Correct answerWash hands.
Put on gloves.
Place the drop in the conjunctival sac.
Pull the lower lid down against the cheek bone.
A client is receiving meperidine hydrochloride (Demerol) for pain. Which of the
following are side effects of this medication Correct answerHypotension
Tremors
Drowsiness
Which interventions would apply in the care of a client at high risk for an allergic
response to a latex allergy. Correct answerUse non-latex gloves.
Use medications from glass ampules
Keep a latex-safe supply cart available in the client's area.
Do not puncture rubber stoppers with needles
Ketoconazole is prescribed for a client with a diagnosis of candidiasis. Select the
interventions that the NURS includes when administering this medication Correct
answerMonitor hepatic and liver function studies.
Instruct the client to avoid alcohol.
Instruct the client to avoid exposure to the sun.
A client with human immunodeficiency virus is taking nevirapine (Viramune). The
NURS should monitor for which adverse effects of the medication? Correct
answerHepatotoxicity
Rash
The NURS in the mental health unit reviews the therapeutic and nontherapeutic
communication techniques with a nursing student. Which of the following are
therapeutic communication techniques? Correct answerRestating
Listening
Maintaining neutral responses
Providing acknowledgment and feedback
, Which nursing interventions are appropriate for a hospitalized client with mania
who is exhibiting manipulative behavior? Correct answerAssist the client in
developing means of setting limits on personal behavior.
Follow through about the consequences of behavior in a nonpunitive manner.
Be clear with the client regarding the consequences of exceeding limits set
regarding behavior.
Communicate expected behaviors to the client.
Which of the following are appropriate interventions for caring for the client in
alcohol withdrawal Correct answerMonitor vital signs.
Provide a safe environment.
Address hallucinations therapeutically.
Provide reality orientation as appropriate.
A NURS is preparing to care for a dying client, and several family members are at
the client's bedside. Which therapeutic techniques should the NURS use when
communicating with the family. Correct answerExtend touch and hold the client's
or family member's hand if appropriate.
Be honest and truthful and let the client and family know that you will not abandon
them
Encourage expression of feelings, concerns, and fears.
A hospitalized client is started on phenelzine sulfate (Nardil) for the treatment of
depression. The NURS instructs the client to avoid consuming which foods while
taking this medication? Correct answerFigs
Yogurt
Aged cheese
A client enters the emergency room confused, twitching, and having seizures. His
family states he recently was placed on corticosteroids for arthritis and was feeling
better and exercising daily. Upon assessment, 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. Correct answerMonitor intake and output.
Monitor the vital signs.
Monitor the electrolyte levels.
Increase water intake orally.
Provide a sodium-reduced diet.
