NCLEX PN SATA QUESTIONS AND ANSWERS
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
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)
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
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.
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
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.
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.
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.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
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)
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
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.
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
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.
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.
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:
