Advanced Next-Gen NCLEX SATA Questions And Correct Verified Answers With Rationales
Case-Based·Clinical Judgment·Prioritization
1. Heart Failure Exacerbation
A client with heart failure arrives at the ED with shortness of breath. Assessment findings include BP 168/92
mmHg,HR 118/min, RR 30/min, SpO2 86%, bilateral crackles, and 3+ pitting edema.
Which nursing interventions should the nurse implement immediately? (Select all that apply.)
A.Place the client in high-Fowler's position
B. Administer oxygen as prescribed
C. Encourage oral fluids
D. Assess lung sounds frequently
E. Prepare to administer IV furosemide
F.Place the client flat in bed
Answer:A, B, D, E
Rationale: The client is experiencing acute pulmonary edema. High-Fowler's position improves lung expansion,
oxygen treats hypoxemia, lung assessments monitor response, and IV furosemide reduces fluid overload.
2. Hyperkalemia
A client with acute kidney injury has the following laboratory values:
· Potassium: 6.8 mEq/L
·Creatinine: 3.5 mg/dL
· BUN:48 mg/dL
Which findings should the nurse anticipate? (Select all that apply.)
A.Peaked T waves
B.Muscle weakness
C.Ventricular dysrhythmias
D. Increased bowel motility
E. Flaccid paralysis
Answer:A, B,C,E
Rationale: Severe hyperkalemia affects cardiac conduction and skeletal muscles, causing weakness,paralysis,
peaked T waves, and potentially lethal dysrhythmias.
3. Myocardial Infarction
, A client reports crushing chest pain radiating to the left arm.
Which findings support a diagnosis of myocardial infarction? (Select all that apply.)
A. Elevated troponin level
B.ST-segment elevation
C. Diaphoresis
D. Chest pain relieved by nitroglycerin immediately
E. Nausea and vomiting
Answer:A, B, C, E
Rationale:Elevated cardiac biomarkers, ST elevation, diaphoresis, nausea, and persistent chest pain are
classic MI findings.
4.DKA
A client with type 1 diabetes presents with:
·Glucose 620 mg/dL
· pH 7.20
· HCO3 14 mEq/L
Which findings are expected? (Select all that apply.)
A.Fruity breath odor
B. Kussmaul respirations
C. Dehydration
D. Hyperkalemia initially
E.Bradycardia
Answer: A, B, C,D
Rationale: DKA causes metabolic acidosis, compensatory Kussmaul respirations,dehydration,fruity breath,
and elevated serum potassium despite total body potassium depletion.
5.Increased Intracranial Pressure
A client with traumatic brain injury develops increasing ICP.
Which findings require immediate intervention? (Select all that apply.)
A. Unequal pupils
B.Decreased level of consciousness
C. Projectile vomiting
D. Bradycardia
E.Glasgow Coma Scale improvement
Case-Based·Clinical Judgment·Prioritization
1. Heart Failure Exacerbation
A client with heart failure arrives at the ED with shortness of breath. Assessment findings include BP 168/92
mmHg,HR 118/min, RR 30/min, SpO2 86%, bilateral crackles, and 3+ pitting edema.
Which nursing interventions should the nurse implement immediately? (Select all that apply.)
A.Place the client in high-Fowler's position
B. Administer oxygen as prescribed
C. Encourage oral fluids
D. Assess lung sounds frequently
E. Prepare to administer IV furosemide
F.Place the client flat in bed
Answer:A, B, D, E
Rationale: The client is experiencing acute pulmonary edema. High-Fowler's position improves lung expansion,
oxygen treats hypoxemia, lung assessments monitor response, and IV furosemide reduces fluid overload.
2. Hyperkalemia
A client with acute kidney injury has the following laboratory values:
· Potassium: 6.8 mEq/L
·Creatinine: 3.5 mg/dL
· BUN:48 mg/dL
Which findings should the nurse anticipate? (Select all that apply.)
A.Peaked T waves
B.Muscle weakness
C.Ventricular dysrhythmias
D. Increased bowel motility
E. Flaccid paralysis
Answer:A, B,C,E
Rationale: Severe hyperkalemia affects cardiac conduction and skeletal muscles, causing weakness,paralysis,
peaked T waves, and potentially lethal dysrhythmias.
3. Myocardial Infarction
, A client reports crushing chest pain radiating to the left arm.
Which findings support a diagnosis of myocardial infarction? (Select all that apply.)
A. Elevated troponin level
B.ST-segment elevation
C. Diaphoresis
D. Chest pain relieved by nitroglycerin immediately
E. Nausea and vomiting
Answer:A, B, C, E
Rationale:Elevated cardiac biomarkers, ST elevation, diaphoresis, nausea, and persistent chest pain are
classic MI findings.
4.DKA
A client with type 1 diabetes presents with:
·Glucose 620 mg/dL
· pH 7.20
· HCO3 14 mEq/L
Which findings are expected? (Select all that apply.)
A.Fruity breath odor
B. Kussmaul respirations
C. Dehydration
D. Hyperkalemia initially
E.Bradycardia
Answer: A, B, C,D
Rationale: DKA causes metabolic acidosis, compensatory Kussmaul respirations,dehydration,fruity breath,
and elevated serum potassium despite total body potassium depletion.
5.Increased Intracranial Pressure
A client with traumatic brain injury develops increasing ICP.
Which findings require immediate intervention? (Select all that apply.)
A. Unequal pupils
B.Decreased level of consciousness
C. Projectile vomiting
D. Bradycardia
E.Glasgow Coma Scale improvement
