NGN NCLEX SATA Real Exam 2026 Edition Questions And Correct Answers
SCORE INTERPRETATION
Score Suggested Interpretation
113-125(90-100%) Excellent-strong NCLEX clinical judgment
100-112(80-89%) Very Good-continue strengthening weak areas
88-99(70-79%) Fair-focused review recommended
75-87(60-69%) Needs Improvement-strengthen fundamentals and prioritization
Below 75 Intensive review recommended
1. A nurse is caring for a client at high risk for falls. Which interventions are appropriate?
A.Keep the bed in the lowest position.
B.Keep frequently used items within reach.
C. Raise all four side rails continuously.
D. Ensure nonskid footwear is used.
E.Keep the call bell within reach.
F. Encourage the client to ambulate independently.
Answer: A, B,D, E
Rationale: Low bed position, accessible belongings, nonskid footwear, and a reachable call bell redduce
fall risk. Four raised side rails can constitute a restraint, and an at-risk client should not ambulate
independently unless assessed as safe.
2. Which findings require immediate nursing follow-up?
A. Oxygen saturation of 86%
B.New-onset confusion
C.Heart rate of 78/min
D.Stridor
E. Urine output of 15 mL/hr
F.Temperature of 37.1℃
Answer: A, B,D,E
Rationale: Hypoxemia, acute confusion, stridor, and significantly decreased urine output may indicate
serious deterioration. Normal heart rate and temperature are not immediate concerns.
3.Which actions are included in standard precautions?
A. Perform hand hygiene before and afterclient contact.
B. Wear gloves when contact with blood is anticipated.
C. Use eye protection if splashing is possible.
D. Wear an N95 respirator for every client.
E. Dispose of sharps in puncture-resistant containers.
F.Recap used needles with two hands.
Answer: A, B, C, E
Rationale: Standard precautions include hand hygiene, appropriate PPE based on exposure risk, and safe
sharps disposal. N95 respirators are not universally required, and needles should not routinely be recapped.
4. Which clients should the nurse assess first?
A. A client with asthma who has minimal air movement
B.A postoperative client reporting pain 7/10
C. A client with chest pain and diaphoresis
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,D.A client with sudden unilateral weakness
E.A client requesting assistance to the bathroom
F.A client with stridor after extubation
Answer: A, C, D, F
Rationale: Severe respiratory compromise, possible myocardial infarction, acute stroke, and upper-airway
obstruction are high-priority threats involving airway, breathing, and circulation.
5. Which findings are signs of hypoxia?
A.Restlessness
B. Confusion
C.Cyanosis
D.Tachycardia
E.Bradycardia as an early sign
F.Decreased level of consciousness
Answer: A, B, C, D,F
Rationale:Early hypoxia commonly causes restlessness, confusion, and tachycardia, Severe hypoxia may cause
cyanosis and decreased consciousness. Bradycardia is generally a late sign.
6. Which interventions help prevent pressure injuries?
A. Reposition immobile clients regularly.
B.Keep skin clean and dry.
C.Massage reddened bony prominences.
D.Use pressure-redistributing surfaces when indicated.
E.Maintain adequate nutrition and hydration.
F.Place donut-shaped devices under the sacrum routinely.
Answer: A, B, D, E
Rationale: Repositioning, moisture management, pressure redistribution, and adequate nutrition support skin
integrity. Reddened areas should not be massaged, and donut devices can increase localized pressure.
7. Which findings are consistent with dehydration?
A. Dry mucous membranes
B.Tachycardia
C. Concentrated urine
D.Weight gain
E.Orthostatic hypotension
F.Poor skin turgor
Answer:A, B,C,E,F
Rationale: Fluid deficit commonly produces dry mucosa, tachycardia, concentrated urine,orthostatic hypotension,
and decreased skin turgor. Weight gain is more typical of fluid excess.
8. Which measures reduce aspiration risk during enteral feeding?
A.Elevate the head of the bed.
B. Verify feeding-tube placement according to facility policy.
C.Place the client flat after feeding.
D.Monitor for feeding intolerance.
E.Maintain appropriate head elevation after feeding.
F.Add blue dye to the formula.
Answer: A, B, D, E
Rationale: Proper positioning, tube-placement verification, and monitoring for intolerance reduce aspiration
risk. Flat positioning increases risk, and dye is not recommended.
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, 9.Which are appropriate restraints-related nursing actions?
A. Use restraints only when less restrictive measures are ineffective.
B. Obtain the required prescription according to policy.
C. Secure restraints to side rails.
D.Assess circulation regularly.
E. Remove restraints periodically as appropriate.
F. Use restraints for staff convenience.
Answer: A, B, D, E
Rationale: Restraints require justification, authorization, frequent monitoring, and reassessment.
They should be attached to the bed frame rather than movable side rails and never used for
convenience.
10. Which are signs of infection at a surgical wound?
A.Increasing redness
B. Purulent drainage
C.Increasing warmth
D.Increasing pain
E.Well-approximated wound edges
F.Fever
Answer:A, B, C, D, F
Rationale: Redness, warmth, pain, purulent drainage, and fever can indicate infection. Well-
approximated edges generally indicate expected healing.
11.Which interventions are appropriate for seizure precautions?
A. Pad side rails when indicated.
B. Keep suction equipment available.
C. Insert a tongue blade during a seizure.
D.Keep oxygen available.
E.Maintain the bed in a low position.
F.Restrain the client's extremities during seizure activity.
Answer: A, B, D,E
Rationale: Protect the client from injury and support oxygenation. Nothing should be forced into the mouth,
and extremities should not be restrained.
12. During an active generalized seizure, which actions should the nurse take?
A. Protect the client's head.
B. Turn the client to the side when possible.
C.Place an object in the mouth.
D.Time the seizure.
E.Remove nearby hazards.
F. Hold the client firmly in place.
Answer:A,B,D,E
Rationale: Protecting the airway and preventing injury are priorities. Do not place anything in the mouth
or forcibly restrain the client.
13. Which clients are at increased risk for healthcare-associated infections?
A.Client with an indwelling urinary catheter
B. Client with a central venous catheter
C. Client receiving immunosuppressive therapy
D.Healthy client admitted for observation
E.Client receiving mechanical ventilation
F.Client with prolonged hospitalization
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SCORE INTERPRETATION
Score Suggested Interpretation
113-125(90-100%) Excellent-strong NCLEX clinical judgment
100-112(80-89%) Very Good-continue strengthening weak areas
88-99(70-79%) Fair-focused review recommended
75-87(60-69%) Needs Improvement-strengthen fundamentals and prioritization
Below 75 Intensive review recommended
1. A nurse is caring for a client at high risk for falls. Which interventions are appropriate?
A.Keep the bed in the lowest position.
B.Keep frequently used items within reach.
C. Raise all four side rails continuously.
D. Ensure nonskid footwear is used.
E.Keep the call bell within reach.
F. Encourage the client to ambulate independently.
Answer: A, B,D, E
Rationale: Low bed position, accessible belongings, nonskid footwear, and a reachable call bell redduce
fall risk. Four raised side rails can constitute a restraint, and an at-risk client should not ambulate
independently unless assessed as safe.
2. Which findings require immediate nursing follow-up?
A. Oxygen saturation of 86%
B.New-onset confusion
C.Heart rate of 78/min
D.Stridor
E. Urine output of 15 mL/hr
F.Temperature of 37.1℃
Answer: A, B,D,E
Rationale: Hypoxemia, acute confusion, stridor, and significantly decreased urine output may indicate
serious deterioration. Normal heart rate and temperature are not immediate concerns.
3.Which actions are included in standard precautions?
A. Perform hand hygiene before and afterclient contact.
B. Wear gloves when contact with blood is anticipated.
C. Use eye protection if splashing is possible.
D. Wear an N95 respirator for every client.
E. Dispose of sharps in puncture-resistant containers.
F.Recap used needles with two hands.
Answer: A, B, C, E
Rationale: Standard precautions include hand hygiene, appropriate PPE based on exposure risk, and safe
sharps disposal. N95 respirators are not universally required, and needles should not routinely be recapped.
4. Which clients should the nurse assess first?
A. A client with asthma who has minimal air movement
B.A postoperative client reporting pain 7/10
C. A client with chest pain and diaphoresis
1|Page
,D.A client with sudden unilateral weakness
E.A client requesting assistance to the bathroom
F.A client with stridor after extubation
Answer: A, C, D, F
Rationale: Severe respiratory compromise, possible myocardial infarction, acute stroke, and upper-airway
obstruction are high-priority threats involving airway, breathing, and circulation.
5. Which findings are signs of hypoxia?
A.Restlessness
B. Confusion
C.Cyanosis
D.Tachycardia
E.Bradycardia as an early sign
F.Decreased level of consciousness
Answer: A, B, C, D,F
Rationale:Early hypoxia commonly causes restlessness, confusion, and tachycardia, Severe hypoxia may cause
cyanosis and decreased consciousness. Bradycardia is generally a late sign.
6. Which interventions help prevent pressure injuries?
A. Reposition immobile clients regularly.
B.Keep skin clean and dry.
C.Massage reddened bony prominences.
D.Use pressure-redistributing surfaces when indicated.
E.Maintain adequate nutrition and hydration.
F.Place donut-shaped devices under the sacrum routinely.
Answer: A, B, D, E
Rationale: Repositioning, moisture management, pressure redistribution, and adequate nutrition support skin
integrity. Reddened areas should not be massaged, and donut devices can increase localized pressure.
7. Which findings are consistent with dehydration?
A. Dry mucous membranes
B.Tachycardia
C. Concentrated urine
D.Weight gain
E.Orthostatic hypotension
F.Poor skin turgor
Answer:A, B,C,E,F
Rationale: Fluid deficit commonly produces dry mucosa, tachycardia, concentrated urine,orthostatic hypotension,
and decreased skin turgor. Weight gain is more typical of fluid excess.
8. Which measures reduce aspiration risk during enteral feeding?
A.Elevate the head of the bed.
B. Verify feeding-tube placement according to facility policy.
C.Place the client flat after feeding.
D.Monitor for feeding intolerance.
E.Maintain appropriate head elevation after feeding.
F.Add blue dye to the formula.
Answer: A, B, D, E
Rationale: Proper positioning, tube-placement verification, and monitoring for intolerance reduce aspiration
risk. Flat positioning increases risk, and dye is not recommended.
2|Page
, 9.Which are appropriate restraints-related nursing actions?
A. Use restraints only when less restrictive measures are ineffective.
B. Obtain the required prescription according to policy.
C. Secure restraints to side rails.
D.Assess circulation regularly.
E. Remove restraints periodically as appropriate.
F. Use restraints for staff convenience.
Answer: A, B, D, E
Rationale: Restraints require justification, authorization, frequent monitoring, and reassessment.
They should be attached to the bed frame rather than movable side rails and never used for
convenience.
10. Which are signs of infection at a surgical wound?
A.Increasing redness
B. Purulent drainage
C.Increasing warmth
D.Increasing pain
E.Well-approximated wound edges
F.Fever
Answer:A, B, C, D, F
Rationale: Redness, warmth, pain, purulent drainage, and fever can indicate infection. Well-
approximated edges generally indicate expected healing.
11.Which interventions are appropriate for seizure precautions?
A. Pad side rails when indicated.
B. Keep suction equipment available.
C. Insert a tongue blade during a seizure.
D.Keep oxygen available.
E.Maintain the bed in a low position.
F.Restrain the client's extremities during seizure activity.
Answer: A, B, D,E
Rationale: Protect the client from injury and support oxygenation. Nothing should be forced into the mouth,
and extremities should not be restrained.
12. During an active generalized seizure, which actions should the nurse take?
A. Protect the client's head.
B. Turn the client to the side when possible.
C.Place an object in the mouth.
D.Time the seizure.
E.Remove nearby hazards.
F. Hold the client firmly in place.
Answer:A,B,D,E
Rationale: Protecting the airway and preventing injury are priorities. Do not place anything in the mouth
or forcibly restrain the client.
13. Which clients are at increased risk for healthcare-associated infections?
A.Client with an indwelling urinary catheter
B. Client with a central venous catheter
C. Client receiving immunosuppressive therapy
D.Healthy client admitted for observation
E.Client receiving mechanical ventilation
F.Client with prolonged hospitalization
3|Page
