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NCLEX 2025 SATA Challenge | 180 Select-
All-That-Apply Questions with Detailed
Answer Rationales
1. Cardiac – Heart Failure
A nurse is caring for a client with new-onset heart failure. Which findings should
the nurse expect? Select all that apply.
A. Dyspnea on exertion
B. Peripheral edema
C. Bradycardia
D. Jugular venous distention
E. Dry cough
, 2
Answer: A, B, D
Rationale:
Heart failure causes fluid overload and decreased cardiac output. Dyspnea on
exertion and JVD occur from fluid backing up into the lungs and venous system.
Peripheral edema results from venous congestion. Bradycardia is not typical;
tachycardia is a compensatory response. Dry cough is more related to ACE
inhibitor therapy, not primary heart failure symptoms.
2. Endocrine – Hypoglycemia
A diabetic client becomes diaphoretic and tremulous while waiting for lunch.
Which findings support hypoglycemia? Select all that apply.
A. Pallor
B. Shakiness
C. Polyuria
D. Confusion
E. Fruity breath odor
Answer: A, B, D
, 3
Rationale:
Hypoglycemia presents with SNS activation (sweating, pallor, tremors) and CNS
depression (confusion, irritability). Polyuria and fruity breath odor are
hyperglycemia/DKA signs, not hypoglycemia.
3. Respiratory – Asthma Attack
The nurse is caring for a client in an acute asthma exacerbation. Which clinical
findings are expected? Select all that apply.
A. Wheezing
B. Prolonged expiratory phase
C. Cyanosis
D. Use of accessory muscles
E. Decreased breath sounds
Answer: A, B, D, E
Rationale:
Asthma causes airway obstruction and bronchospasm, leading to wheezing,
prolonged expiration, accessory muscle use, and diminished breath sounds in
severe cases. Cyanosis occurs only in late, severe hypoxia.
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4. GI – Cholecystitis
Which signs and symptoms would the nurse expect in a client with acute
cholecystitis? Select all that apply.
A. Right upper quadrant pain
B. Pain radiating to the right shoulder
C. Steatorrhea
D. Murphy’s sign
E. Clay-colored stools
Answer: A, B, D, E
Rationale:
Cholecystitis causes RUQ pain often radiating to the right shoulder, positive
Murphy’s sign (pain with inspiration during palpation), and clay-colored stools
from bile obstruction. Steatorrhea is seen more with chronic biliary obstruction or
pancreatitis.
5. Neuro – Stroke (CVA)
NCLEX 2025 SATA Challenge | 180 Select-
All-That-Apply Questions with Detailed
Answer Rationales
1. Cardiac – Heart Failure
A nurse is caring for a client with new-onset heart failure. Which findings should
the nurse expect? Select all that apply.
A. Dyspnea on exertion
B. Peripheral edema
C. Bradycardia
D. Jugular venous distention
E. Dry cough
, 2
Answer: A, B, D
Rationale:
Heart failure causes fluid overload and decreased cardiac output. Dyspnea on
exertion and JVD occur from fluid backing up into the lungs and venous system.
Peripheral edema results from venous congestion. Bradycardia is not typical;
tachycardia is a compensatory response. Dry cough is more related to ACE
inhibitor therapy, not primary heart failure symptoms.
2. Endocrine – Hypoglycemia
A diabetic client becomes diaphoretic and tremulous while waiting for lunch.
Which findings support hypoglycemia? Select all that apply.
A. Pallor
B. Shakiness
C. Polyuria
D. Confusion
E. Fruity breath odor
Answer: A, B, D
, 3
Rationale:
Hypoglycemia presents with SNS activation (sweating, pallor, tremors) and CNS
depression (confusion, irritability). Polyuria and fruity breath odor are
hyperglycemia/DKA signs, not hypoglycemia.
3. Respiratory – Asthma Attack
The nurse is caring for a client in an acute asthma exacerbation. Which clinical
findings are expected? Select all that apply.
A. Wheezing
B. Prolonged expiratory phase
C. Cyanosis
D. Use of accessory muscles
E. Decreased breath sounds
Answer: A, B, D, E
Rationale:
Asthma causes airway obstruction and bronchospasm, leading to wheezing,
prolonged expiration, accessory muscle use, and diminished breath sounds in
severe cases. Cyanosis occurs only in late, severe hypoxia.
, 4
4. GI – Cholecystitis
Which signs and symptoms would the nurse expect in a client with acute
cholecystitis? Select all that apply.
A. Right upper quadrant pain
B. Pain radiating to the right shoulder
C. Steatorrhea
D. Murphy’s sign
E. Clay-colored stools
Answer: A, B, D, E
Rationale:
Cholecystitis causes RUQ pain often radiating to the right shoulder, positive
Murphy’s sign (pain with inspiration during palpation), and clay-colored stools
from bile obstruction. Steatorrhea is seen more with chronic biliary obstruction or
pancreatitis.
5. Neuro – Stroke (CVA)
