SATA NCLEX Sample questions and correct
answers With Rationale. With Complete Solution
2024/2025.
1. A patient is admitted to the same day surgery unit for liver biopsy. Which of the following
laboratory tests assesses coagulation? Select all that apply.
1. Partial thromboplastin time.
2. Prothrombin time.
3. Platelet count.
4. Hemoglobin
5. Complete Blood Count
6. White Blood Cell Count
Answers and Rationale
1. Answer: 1, 2, and 3
Prothrombin time, partial thromboplastin time, and platelet count are all included in coagulation studies.
The hemoglobin level, though important information prior to an invasive procedure like liver biopsy,
does not assess coagulation.
2. A patient is admitted to the hospital with suspected polycythemia vera. Which of the following
symptoms is consistent with the diagnosis? Select all that apply.
1. Weight loss.
2. Increased clotting time.
3. Hypertension.
4. Headaches.
2. Answer: 2, 3, and 4
Polycythemia vera is a condition in which the bone marrow produces too many red blood cells. This
causes an increase in hematocrit and viscosity of the blood. Patients can experience headaches,
dizziness, and visual disturbances. Cardiovascular effects include increased blood pressure and delayed
clotting time. Weight loss is not a manifestation of polycythemia vera.
3. The nurse is teaching the client how to use a metered dose inhaler (MDI) to administer a
Corticosteroid drug. Which of the following client actions indicates that he is using the MDI correctly?
Select all that apply.
1. The inhaler is held upright.
2. Head is tilted down while inhaling the medication
3. Client waits 5 minutes between puffs.
4. Mouth is rinsed with water following administration
5. Client lies supine for 15 minutes following administration.
3. Answer: 1 and 4.
,4. The nurse is teaching a client with polycythemia vera about potential complications from this
disease. Which manifestations would the nurse include in the client's teaching plan? Select all that
apply.
1. Hearing loss
2. Visual disturbance
3. Headache
4. Orthopnea5. Gout6. Weight loss
4. Answers: 2, 3, 4 and 5.
Polycythemia vera, a condition in which too many RBCs are produced in the blood serum, can lead to an
increase in the hematocrit and hypervolemia, hyperviscosity, and hypertension. Subsequently, the client
can experience dizziness, tinnitus, visual disturbances, headaches, or a feeling of fullness in the head.
The client may also experience cardiovascular symptoms such as heart failure (shortness of breath and
orthopnea) and increased clotting time or symptoms of an increased uric acid level such as painful
swollen joints (usually the big toe). Hearing loss and weight loss are not manifestations associated with
polycythemia vera.
5. Which of the following would be priority assessment data to gather from a client who has been
diagnosed with pneumonia? Select all that apply.
1. Auscultation of breath sounds2. Auscultation of bowel sounds3. Presence of chest pain.4. Presence
of peripheral edema5. Color of nail beds
5. Answer: 1, 3, 5.
A respiratory assessment, which includes auscultation of breath sounds and assessing the color of the
nail beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an
important respiratory assessment as chest pain can interfere with the client's ability to breathe deeply.
6. The nurse is teaching a client who has been diagnosed with TB how to avoid spreading the disease
to family members. Which statement(s) by the client indicate(s) that he has understood the nurses
instructions? Select all that apply.
1. "I will need to dispose of my old clothing when I return home."2. "I should always cover my mouth
and nose when sneezing."3. "It is important that I isolate myself from family when possible."4. "I
should use paper tissues to cough in and dispose of them properly."5. "I can use regular plate and
utensils whenever I eat."
6. Answer: 2, 4, 5.
7. The nurse is admitting a client with hypoglycemia. Identify the signs and symptoms the nurse should
expect. Select all that apply.
1. Thirst
2. Palpitations
3. Diaphoresis
4. Slurred speech
5. Hyperventilation
7. Answer: 2, 3, 4.
Palpitations, an adrenergic symptom, occur as the glucose levels fall; the sympathetic nervous system is
,activated and epinephrine and norepinephrine are secreted causing this response. Diaphoresis is a
sympathetic nervous system response that occurs as epinephrine and norepinephrine are released.
Slurred speech is a neuroglycopenic symptom; as the brain receives insufficient glucose, the activity of
the CNS becomes depressed.
8. Which adaptations should the nurse caring for a client with diabetic ketoacidosis expect the client to
exhibit? Select all that apply:
1. Sweating
2. Low PCO2
3. Retinopathy
4. Acetone breath
5. Elevated serum bicarbonate
8. Answer: 2, 4.
Metabolic acidosis initiates respiratory compensation in the form of Kussmaul respirations to counteract
the effects of ketone buildup, resulting in a lowered PCO2. A fruity odor to the breath (acetone breath)
occurs when the ketone level is elevated in ketoacidosis.
9. When planning care for a client with ulcerative colitis who is experiencing symptoms, which client
care activities can the nurse appropriately delegate to a unlicensed assistant? Select all that apply.
1. Assessing the client's bowel sounds
2. Providing skin care following bowel movements
3. Evaluating the client's response to antidiarrheal medications
4. Maintaining intake and output records
5. Obtaining the client's weight.
9. Answer: 2, 4, and 5.
The nurse can delegate the following basic care activities to the unlicensed assistant: providing skin care
following bowel movements, maintaining intake and output records, and obtaining the client's weight.
Assessing the client's bowel sounds and evaluating the client's response to medication are registered
nurse activities that cannot be delegated.
10. Which of the following nursing diagnoses would be appropriate for a client with heart failure?
Select all that apply.
1. Ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased
cardiac output.
2. Activity intolerance related to increased cardiac output.
3. Decreased cardiac output related to structural and functional changes.
4. Impaired gas exchange related to decreased sympathetic nervous system activity.
10. Answer: 1 and 3.
HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart muscle
becomes weak and does not adequately pump the blood out of the chambers. As a result, blood pools in
the left ventricle and backs up into the left atrium, and eventually into the lungs. Therefore, greater
amounts of blood remain in the ventricle after contraction thereby decreasing cardiac output. In
addition, this pooling leads to thrombus formation and ineffective tissue perfusion because of the
decrease in blood flow to the other organs and tissues of the body. Typically, these clients have an
, ejection fraction of less than 50% and poorly tolerate activity. Activity intolerance is related to a
decrease, not increase, in cardiac output. Gas exchange is impaired. However, the decrease in cardiac
output triggers compensatory mechanisms, such as an increase in sympathetic nervous system activity.
11. When caring for a client with a central venous line, which of the following nursing actions should
be implemented in the plan of care for chemotherapy administration? Select all that apply.
1. Verify patency of the line by the presence of a blood return at regular intervals.
2. Inspect the insertion site for swelling, erythema, or drainage.
3. Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.
4. If unable to aspirate blood, reposition the client and encourage the client to cough.
5. Contact the health care provider about verifying placement if the status is questionable.
11. Answer: 1, 2, 4, 5.
A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation.
The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when
administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines
apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous
access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall
or may indicate the line has occlusion. Having the client cough or move position may change the status
of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray
study to verify placement if the status is questionable and may require a declotting regimen.
12. A 20-year old college student has been brought to the psychiatric hospital by her parents. Her
admitting diagnosis is borderline personality disorder. When talking with the parents, which
information would the nurse expect to be included in the client's history? Select all that apply.
1. Impulsiveness2. Lability of mood3. Ritualistic behavior4. psychomotor retardation5. Self-destructive
behavior
12. Answer: 1, 2, 5.
13. When assessing a client diagnosed with impulse control disorder, the nurse observes violent,
aggressive, and assaultive behavior. Which of the following assessment data 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 the 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 anger.
13. Answer: 1, 2, 4.
A client with an impulse control disorder who displays violent, aggressive, and assaultive behavior
generally functions well in other areas of his life. The degree of aggressiveness is typically out of
proportion with the stressor. Such a client commonly has a history of parental alcoholism and a chaotic
family life, and often verbalizes sincere remorse and guilt for the aggressive behavior.
14. Which of the following nursing interventions are written correctly? (Select all that apply.)
1. Apply continuous passive motion machine during day.
answers With Rationale. With Complete Solution
2024/2025.
1. A patient is admitted to the same day surgery unit for liver biopsy. Which of the following
laboratory tests assesses coagulation? Select all that apply.
1. Partial thromboplastin time.
2. Prothrombin time.
3. Platelet count.
4. Hemoglobin
5. Complete Blood Count
6. White Blood Cell Count
Answers and Rationale
1. Answer: 1, 2, and 3
Prothrombin time, partial thromboplastin time, and platelet count are all included in coagulation studies.
The hemoglobin level, though important information prior to an invasive procedure like liver biopsy,
does not assess coagulation.
2. A patient is admitted to the hospital with suspected polycythemia vera. Which of the following
symptoms is consistent with the diagnosis? Select all that apply.
1. Weight loss.
2. Increased clotting time.
3. Hypertension.
4. Headaches.
2. Answer: 2, 3, and 4
Polycythemia vera is a condition in which the bone marrow produces too many red blood cells. This
causes an increase in hematocrit and viscosity of the blood. Patients can experience headaches,
dizziness, and visual disturbances. Cardiovascular effects include increased blood pressure and delayed
clotting time. Weight loss is not a manifestation of polycythemia vera.
3. The nurse is teaching the client how to use a metered dose inhaler (MDI) to administer a
Corticosteroid drug. Which of the following client actions indicates that he is using the MDI correctly?
Select all that apply.
1. The inhaler is held upright.
2. Head is tilted down while inhaling the medication
3. Client waits 5 minutes between puffs.
4. Mouth is rinsed with water following administration
5. Client lies supine for 15 minutes following administration.
3. Answer: 1 and 4.
,4. The nurse is teaching a client with polycythemia vera about potential complications from this
disease. Which manifestations would the nurse include in the client's teaching plan? Select all that
apply.
1. Hearing loss
2. Visual disturbance
3. Headache
4. Orthopnea5. Gout6. Weight loss
4. Answers: 2, 3, 4 and 5.
Polycythemia vera, a condition in which too many RBCs are produced in the blood serum, can lead to an
increase in the hematocrit and hypervolemia, hyperviscosity, and hypertension. Subsequently, the client
can experience dizziness, tinnitus, visual disturbances, headaches, or a feeling of fullness in the head.
The client may also experience cardiovascular symptoms such as heart failure (shortness of breath and
orthopnea) and increased clotting time or symptoms of an increased uric acid level such as painful
swollen joints (usually the big toe). Hearing loss and weight loss are not manifestations associated with
polycythemia vera.
5. Which of the following would be priority assessment data to gather from a client who has been
diagnosed with pneumonia? Select all that apply.
1. Auscultation of breath sounds2. Auscultation of bowel sounds3. Presence of chest pain.4. Presence
of peripheral edema5. Color of nail beds
5. Answer: 1, 3, 5.
A respiratory assessment, which includes auscultation of breath sounds and assessing the color of the
nail beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an
important respiratory assessment as chest pain can interfere with the client's ability to breathe deeply.
6. The nurse is teaching a client who has been diagnosed with TB how to avoid spreading the disease
to family members. Which statement(s) by the client indicate(s) that he has understood the nurses
instructions? Select all that apply.
1. "I will need to dispose of my old clothing when I return home."2. "I should always cover my mouth
and nose when sneezing."3. "It is important that I isolate myself from family when possible."4. "I
should use paper tissues to cough in and dispose of them properly."5. "I can use regular plate and
utensils whenever I eat."
6. Answer: 2, 4, 5.
7. The nurse is admitting a client with hypoglycemia. Identify the signs and symptoms the nurse should
expect. Select all that apply.
1. Thirst
2. Palpitations
3. Diaphoresis
4. Slurred speech
5. Hyperventilation
7. Answer: 2, 3, 4.
Palpitations, an adrenergic symptom, occur as the glucose levels fall; the sympathetic nervous system is
,activated and epinephrine and norepinephrine are secreted causing this response. Diaphoresis is a
sympathetic nervous system response that occurs as epinephrine and norepinephrine are released.
Slurred speech is a neuroglycopenic symptom; as the brain receives insufficient glucose, the activity of
the CNS becomes depressed.
8. Which adaptations should the nurse caring for a client with diabetic ketoacidosis expect the client to
exhibit? Select all that apply:
1. Sweating
2. Low PCO2
3. Retinopathy
4. Acetone breath
5. Elevated serum bicarbonate
8. Answer: 2, 4.
Metabolic acidosis initiates respiratory compensation in the form of Kussmaul respirations to counteract
the effects of ketone buildup, resulting in a lowered PCO2. A fruity odor to the breath (acetone breath)
occurs when the ketone level is elevated in ketoacidosis.
9. When planning care for a client with ulcerative colitis who is experiencing symptoms, which client
care activities can the nurse appropriately delegate to a unlicensed assistant? Select all that apply.
1. Assessing the client's bowel sounds
2. Providing skin care following bowel movements
3. Evaluating the client's response to antidiarrheal medications
4. Maintaining intake and output records
5. Obtaining the client's weight.
9. Answer: 2, 4, and 5.
The nurse can delegate the following basic care activities to the unlicensed assistant: providing skin care
following bowel movements, maintaining intake and output records, and obtaining the client's weight.
Assessing the client's bowel sounds and evaluating the client's response to medication are registered
nurse activities that cannot be delegated.
10. Which of the following nursing diagnoses would be appropriate for a client with heart failure?
Select all that apply.
1. Ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased
cardiac output.
2. Activity intolerance related to increased cardiac output.
3. Decreased cardiac output related to structural and functional changes.
4. Impaired gas exchange related to decreased sympathetic nervous system activity.
10. Answer: 1 and 3.
HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart muscle
becomes weak and does not adequately pump the blood out of the chambers. As a result, blood pools in
the left ventricle and backs up into the left atrium, and eventually into the lungs. Therefore, greater
amounts of blood remain in the ventricle after contraction thereby decreasing cardiac output. In
addition, this pooling leads to thrombus formation and ineffective tissue perfusion because of the
decrease in blood flow to the other organs and tissues of the body. Typically, these clients have an
, ejection fraction of less than 50% and poorly tolerate activity. Activity intolerance is related to a
decrease, not increase, in cardiac output. Gas exchange is impaired. However, the decrease in cardiac
output triggers compensatory mechanisms, such as an increase in sympathetic nervous system activity.
11. When caring for a client with a central venous line, which of the following nursing actions should
be implemented in the plan of care for chemotherapy administration? Select all that apply.
1. Verify patency of the line by the presence of a blood return at regular intervals.
2. Inspect the insertion site for swelling, erythema, or drainage.
3. Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.
4. If unable to aspirate blood, reposition the client and encourage the client to cough.
5. Contact the health care provider about verifying placement if the status is questionable.
11. Answer: 1, 2, 4, 5.
A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation.
The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when
administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines
apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous
access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall
or may indicate the line has occlusion. Having the client cough or move position may change the status
of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray
study to verify placement if the status is questionable and may require a declotting regimen.
12. A 20-year old college student has been brought to the psychiatric hospital by her parents. Her
admitting diagnosis is borderline personality disorder. When talking with the parents, which
information would the nurse expect to be included in the client's history? Select all that apply.
1. Impulsiveness2. Lability of mood3. Ritualistic behavior4. psychomotor retardation5. Self-destructive
behavior
12. Answer: 1, 2, 5.
13. When assessing a client diagnosed with impulse control disorder, the nurse observes violent,
aggressive, and assaultive behavior. Which of the following assessment data 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 the 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 anger.
13. Answer: 1, 2, 4.
A client with an impulse control disorder who displays violent, aggressive, and assaultive behavior
generally functions well in other areas of his life. The degree of aggressiveness is typically out of
proportion with the stressor. Such a client commonly has a history of parental alcoholism and a chaotic
family life, and often verbalizes sincere remorse and guilt for the aggressive behavior.
14. Which of the following nursing interventions are written correctly? (Select all that apply.)
1. Apply continuous passive motion machine during day.
