SATA NCLEX SAUNDERS EXAM REVIEW. 159
QUESTIONS AND CORRECT ANSWERS, WITH
COMPLETE SOLUTION 2024.
Rifabutin (Mycobutin) is prescribed for a client with active Mycobacterium avium complex (MAC)
disease and tuberculosis. The nurse monitors for which side effects of the medication?
Signs of hepatitis
Flu-like syndrome
Low neutrophil count
Ocular pain or blurred vision
A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme
dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse
immediately notifies the registered nurse and expects which interventions to be prescribed?
Administering 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 nurse administers nitroglycerin, 0.4 mg, sublingually. After 5 minutes,
the client states, "My chest still hurts." Select the appropriate actions that the nurse should take.
Assess the client's pain level.
Check the client's blood pressure.
Administer a second nitroglycerin, 0.4 mg, sublingually.
Contact the registered nurse.
The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than
the inflow. The nurse should take which actions?
Check 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 nurse is preparing a teaching plan for a client who is undergoing cataract extraction with
intraocular implant. Which home care measures will the nurse include in the plan?
To 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 nurse is preparing to administer eye drops. Select the interventions that the nurse takes to
administer the drops
Wash 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
Hypotension
Tremors
Drowsiness
A nurse 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 nurse include on the list?
Keep 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 nurse 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 nurse include on the list?
Symptom 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
Which interventions would apply in the care of a client at high risk for an allergic response to a latex
allergy.
Use 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
nurse includes when administering this medication
Monitor 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 nurse should
monitor for which adverse effects of the medication?
Hepatotoxicity
Rash
,The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication
techniques with a nursing student. Which of the following are therapeutic communication techniques?
Restating
Listening
Maintaining neutral responses
Providing acknowledgment and feedback
Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting
manipulative behavior?
Assist 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
Monitor vital signs.
Provide a safe environment.
Address hallucinations therapeutically.
Provide reality orientation as appropriate.
A nurse is preparing to care for a dying client, and several family members are at the client's bedside.
Which therapeutic techniques should the nurse use when communicating with the family.
Extend 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
nurse instructs the client to avoid consuming which foods while taking this medication?
Figs
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.
Monitor intake and output.
Monitor the vital signs.
Monitor the electrolyte levels.
Increase water intake orally.
Provide a sodium-reduced diet.
, A nurse is preparing to suction an adult client through the client's tracheostomy tube. Which
intervention(s) would the nurse perform for this procedure?
Apply intermittent suction while rotating and withdrawing the catheter.
Advance the catheter until resistance is met and then pull the catheter back 1 cm.
Apply suction for up to 10 to 15 seconds.
Hyperoxygenate the client before suctioning.
Which of these clients are most likely to develop fluid (circulatory) overload?
A premature infant
A 101-year-old man
A client on renal dialysis
A client with congestive heart failure
A nurse is assisting with planning care for a client with an internal radiation implant. Which of the
following should be included in the plan of care?
Wearing gloves when emptying the client's bedpan
Keeping all linens in the room until the implant is removed
Wearing a film (dosimeter) badge when in the client's room
Wearing a lead apron when providing direct care to the client
A community health nurse is conducting a teaching session about terrorism with members of the
community and discussing information regarding anthrax. The nurse tells those attending that anthrax
can be transmitted via which route(s)?
Skin
Inhalation
Gastrointestinal
The nurse is caring for a client after a supratentorial craniotomy in which a large tumor was removed
from the left side. Choose the positions in which the nurse can safely place the client.
In a semi-Fowler's position
With the head in a midline position
A nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who
just returned from the recovery room after a thoracotomy with wedge resection. Which findings
would the nurse expect to note?
50 mL of drainage in the drainage-collection chamber
The drainage system is maintained below the client's chest.
An occlusive dressing is in place over the chest-tube insertion site.
Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation
A nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who
just returned from the recovery room after a thoracotomy with wedge resection. Which findings
would the nurse expect to note?
QUESTIONS AND CORRECT ANSWERS, WITH
COMPLETE SOLUTION 2024.
Rifabutin (Mycobutin) is prescribed for a client with active Mycobacterium avium complex (MAC)
disease and tuberculosis. The nurse monitors for which side effects of the medication?
Signs of hepatitis
Flu-like syndrome
Low neutrophil count
Ocular pain or blurred vision
A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme
dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse
immediately notifies the registered nurse and expects which interventions to be prescribed?
Administering 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 nurse administers nitroglycerin, 0.4 mg, sublingually. After 5 minutes,
the client states, "My chest still hurts." Select the appropriate actions that the nurse should take.
Assess the client's pain level.
Check the client's blood pressure.
Administer a second nitroglycerin, 0.4 mg, sublingually.
Contact the registered nurse.
The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than
the inflow. The nurse should take which actions?
Check 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 nurse is preparing a teaching plan for a client who is undergoing cataract extraction with
intraocular implant. Which home care measures will the nurse include in the plan?
To 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 nurse is preparing to administer eye drops. Select the interventions that the nurse takes to
administer the drops
Wash 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
Hypotension
Tremors
Drowsiness
A nurse 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 nurse include on the list?
Keep 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 nurse 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 nurse include on the list?
Symptom 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
Which interventions would apply in the care of a client at high risk for an allergic response to a latex
allergy.
Use 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
nurse includes when administering this medication
Monitor 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 nurse should
monitor for which adverse effects of the medication?
Hepatotoxicity
Rash
,The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication
techniques with a nursing student. Which of the following are therapeutic communication techniques?
Restating
Listening
Maintaining neutral responses
Providing acknowledgment and feedback
Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting
manipulative behavior?
Assist 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
Monitor vital signs.
Provide a safe environment.
Address hallucinations therapeutically.
Provide reality orientation as appropriate.
A nurse is preparing to care for a dying client, and several family members are at the client's bedside.
Which therapeutic techniques should the nurse use when communicating with the family.
Extend 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
nurse instructs the client to avoid consuming which foods while taking this medication?
Figs
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.
Monitor intake and output.
Monitor the vital signs.
Monitor the electrolyte levels.
Increase water intake orally.
Provide a sodium-reduced diet.
, A nurse is preparing to suction an adult client through the client's tracheostomy tube. Which
intervention(s) would the nurse perform for this procedure?
Apply intermittent suction while rotating and withdrawing the catheter.
Advance the catheter until resistance is met and then pull the catheter back 1 cm.
Apply suction for up to 10 to 15 seconds.
Hyperoxygenate the client before suctioning.
Which of these clients are most likely to develop fluid (circulatory) overload?
A premature infant
A 101-year-old man
A client on renal dialysis
A client with congestive heart failure
A nurse is assisting with planning care for a client with an internal radiation implant. Which of the
following should be included in the plan of care?
Wearing gloves when emptying the client's bedpan
Keeping all linens in the room until the implant is removed
Wearing a film (dosimeter) badge when in the client's room
Wearing a lead apron when providing direct care to the client
A community health nurse is conducting a teaching session about terrorism with members of the
community and discussing information regarding anthrax. The nurse tells those attending that anthrax
can be transmitted via which route(s)?
Skin
Inhalation
Gastrointestinal
The nurse is caring for a client after a supratentorial craniotomy in which a large tumor was removed
from the left side. Choose the positions in which the nurse can safely place the client.
In a semi-Fowler's position
With the head in a midline position
A nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who
just returned from the recovery room after a thoracotomy with wedge resection. Which findings
would the nurse expect to note?
50 mL of drainage in the drainage-collection chamber
The drainage system is maintained below the client's chest.
An occlusive dressing is in place over the chest-tube insertion site.
Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation
A nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who
just returned from the recovery room after a thoracotomy with wedge resection. Which findings
would the nurse expect to note?
