SATA NCLEX Sample

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NCLEX EXAM PREVIEW

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• 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.

• Partial thromboplastin time.
• Prothrombin time.
• Platelet count.
• Hemoglobin
• Complete Blood Count
• 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.

• 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.

• Weight loss.
• Increased clotting time.
• Hypertension.
• 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.

• 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.

• The inhaler is held upright.
• Head is tilted down while inhaling the medication
• Client waits 5 minutes between puffs.
• Mouth is rinsed with water following administration
• Client lies supine for 15 minutes following

administration.

3. Answer: 1 and 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.

• Hearing loss
• Visual disturbance
• Headache
• 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.

• Which of the following would be priority assessment

data to gather from a client who has been diagnosed with pneumonia? Select all that apply.

• 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.

• 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.

• "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.

• The nurse is admitting a client with hypoglycemia.

Identify the signs and symptoms the nurse should expect.Select all that apply.

• Thirst
• Palpitations
• Diaphoresis
• Slurred speech
• 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.

• Which adaptations should the nurse caring for a client

with diabetic ketoacidosis expect the client to exhibit?

Select all that apply:

• Sweating
• Low PCO2
• Retinopathy
• Acetone breath
• 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.

• 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.

• Assessing the client's bowel sounds
• Providing skin care following bowel movements
• Evaluating the client's response to antidiarrheal

medications

• Maintaining intake and output records
• 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.

• Which of the following nursing diagnoses would be

appropriate for a client with heart failure? Select all that apply.

• Ineffective tissue perfusion related to decreased

peripheral blood flow secondary to decreased cardiac output.

• Activity intolerance related to increased cardiac output.
• Decreased cardiac output related to structural and

functional changes.

• 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.

• 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.

• Verify patency of the line by the presence of a blood

return at regular intervals.

• Inspect the insertion site for swelling, erythema, or

drainage.

• Administer a cytotoxic agent to keep the regimen on

schedule even if blood return is not present.

• If unable to aspirate blood, reposition the client and

encourage the client to cough.

• 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.

• 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.

• Impulsiveness2. Lability of mood3. Ritualistic behavior4.

psychomotor retardation5. Self-destructive behavior

12. Answer: 1, 2, 5.

• 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.

• The client functions well in other areas of his life.
• The degree of aggressiveness is out of proportion to

the stressor.

• The violent behavior is most often justified by the

stressor.

• 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.

• Which of the following nursing interventions are

written correctly? (Select all that apply.)

• Apply continuous passive motion machine during day.
• Perform neurovascular checks.
• Elevate head of bed 30 degrees before meals.
• Change dressing once a shift.

14. Answer: 3.

It is specific in what to do and when.

• The nurse is monitoring a client receiving peritoneal

dialysis and nurse notes that a client's outflow is less than the inflow. Select actions that the nurse should take.

• Place the client in good body alignment2. Check the

level of the drainage bag3. Contact the physician

15. Answer: 1, 2, 4, 5.

If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client's position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client's abdomen to enhance gravity drainage. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician.

• The nurse is caring for a hospitalized client who has

chronic renal failure. Which of the following nursing diagnoses are most appropriate for this client? Select all that apply.

• Excess Fluid Volume2. Imbalanced Nutrition; Less than

Body Requirements3. Activity Intolerance4. Impaired Gas Exchange5. Pain.

16. Answer: 1, 2, 3.

Appropriate nursing diagnoses for clients with chronic renal failure include excess fluid volume related to fluid and sodium retention; imbalanced nutrition, less than body requirements related to anorexia, nausea, and vomiting; and activity intolerance related to fatigue. The nursing diagnoses of impaired gas exchange and pain are not commonly related to chronic renal failure.

• The nurse is assessing a child diagnosed with a brain

tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply.

• Head tilt
• Vomiting
• Polydipsia
• Lethargy
• Increased appetite
• Increased pulse

17. Answer: 1, 2, 4.

Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor.