Nclex Sata All Answers Correct 2023

Nclex Sata All Answers Correct 2023 1.The nurse is monitoring a client who is receiving oxytocin (Pitocin) to induce labor. The nurse should be prepared for which maternal adverse reactions? Select all that apply: 1. Hypertension 2. Jaundice 3. Dehydration 4. Fluid overload 5. Uterine tetany 6. Bradycardia Ans- 1, 4, 5 2. 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) Ans- 2, 3, 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 Ans- 1, 3, 5 4. 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. Ans- 1, 2, 5 5. 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 Ans- 4, 5 6. 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. Ans- 1, 2, 3, 4 7. 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. Ans- 1, 2, 4 8. 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. Ans- 3, 4, 5, 6 9. 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. Ans- 1, 3, 5, 6 10.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 Ans- 1, 3, 5, 6 11. 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. Ans- 1, 2, 3, 4 12. The nurse is caring for a client with anorexia nervosa who has a nursing diagnosis of Imbalanced nutrition: Less than body requirements related to dysfunctional eating patterns. Which of the following interventions would be supportive for this client? Select all that apply: 1. Provide small, frequent meals. 2. Monitor weight gain. 3. Allow the client to skip meals until the antidepressant levels are therapeutic. 4. Encourage the client to keep a journal. 5. Monitor the client during meals and for 1 hour after meals. 6. Encourage the client to eat three substantial meals per day. Ans- 1, 2, 4, 5 13. When assessing a client diagnosed with impulse control disorder, the nurse observes violent, aggressive, and assaultive behavior. Which assessment is the nurse also likely to find? Select all that apply: 1. The client functions well in other areas of his life. 2. The degree of aggressiveness is out of proportion to the stressor. 3. The violent behavior is most often justified by a stressor. 4. The client has a history of parental alcoholism and chaotic abusive family life. 5. The client has no remorse about the inability to control his behavior. Ans- 1, 2, 4 14 .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 Ans- 4, 5 15. Which findings are common in neonates born with esophageal atresia? Select all that apply: 1. Decreased production of saliva 2. Cyanosis 3. Coughing 4. Inadequate swallow 5. Choking 6. Inability to cough Ans- 2, 3, 5 16. While preparing a client for an upper GI endoscopy (esophagogastroduodenoscopy), the nurse should implement which interventions? Select all that apply: 1. Administer a preparation to cleanse the GI tract, such as Golytely or Fleets Phospha-Soda. 2. Tell the client he shouldn't eat or drink for 6 to 12 hours before the procedure. 3. Tell the client he must be on a clear liquid diet for 24 hours before the procedure. 4. Inform the client that he'll receive a sedative before the procedure. 5. Tell the client that he may eat and drink immediately after the procedure. Ans- 2, 4 17. A client with a retroperitoneal abscess is receiving gentamicin (Garamycin). Which signs should the nurse monitor? Select all that apply: 1. Hearing 2. Urine output 3. Hematocrit (HCT) 4. Blood urea nitrogen (BUN) and creatinine levels 5. Serum calcium level Ans- 1, 2, 4 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 memb