Ngn nclex rn sata actual exam 2024
1. 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.✅✅ANSWER✅✅✅1, 2,
3, 4
2. 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.✅✅ANSWER✅✅✅1, 2, 4
3. 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. He balances on each foot for at least 6 seconds.
2. He copies a square using straight lines and square
corners.
3. He prepares his own cereal without help.
4. He copies a circle that's closed or very nearly closed.
5. He speaks clearly.
,6. He draws a person with at least three body
parts.✅✅ANSWER✅✅✅3, 4, 5, 6
4. The nurse is caring for a 45-year-old married woman
who has undergone hemicolectomy for colon cancer.
The woman has two children. Which concepts about
families should the nurse keep in mind when providing
care for this client?
Select all that apply:
1. Illness in one family member can affect all members.
2. Family roles don't change because of illness.
3. A family member may have more than one role at a
time in a family.
4. Children typically aren't affected by adult illness.
5. The effects of an illness on a family depend on the
stage of the family's life cycle.
6. Changes in sleeping and eating patterns may be signs
of stress in a family.✅✅ANSWER✅✅✅1, 3, 5, 6
5.A client is receiving chlordiazepoxide (Librium) to
control the symptoms of alcohol withdrawal. The
chlordiazepoxide has been ordered as needed. Which
, symptom may indicate the need for an additional dose
of this medication?
Select all that apply:
1. Tachycardia
2. Mood swings
3. Elevated blood pressure and temperature
4. Piloerection
5. Tremors
6. Increasing anxiety✅✅ANSWER✅✅✅1, 3, 5, 6
6.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✅✅ANSWER✅✅✅1, 4, 5
1. 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.✅✅ANSWER✅✅✅1, 2,
3, 4
2. 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.✅✅ANSWER✅✅✅1, 2, 4
3. 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. He balances on each foot for at least 6 seconds.
2. He copies a square using straight lines and square
corners.
3. He prepares his own cereal without help.
4. He copies a circle that's closed or very nearly closed.
5. He speaks clearly.
,6. He draws a person with at least three body
parts.✅✅ANSWER✅✅✅3, 4, 5, 6
4. The nurse is caring for a 45-year-old married woman
who has undergone hemicolectomy for colon cancer.
The woman has two children. Which concepts about
families should the nurse keep in mind when providing
care for this client?
Select all that apply:
1. Illness in one family member can affect all members.
2. Family roles don't change because of illness.
3. A family member may have more than one role at a
time in a family.
4. Children typically aren't affected by adult illness.
5. The effects of an illness on a family depend on the
stage of the family's life cycle.
6. Changes in sleeping and eating patterns may be signs
of stress in a family.✅✅ANSWER✅✅✅1, 3, 5, 6
5.A client is receiving chlordiazepoxide (Librium) to
control the symptoms of alcohol withdrawal. The
chlordiazepoxide has been ordered as needed. Which
, symptom may indicate the need for an additional dose
of this medication?
Select all that apply:
1. Tachycardia
2. Mood swings
3. Elevated blood pressure and temperature
4. Piloerection
5. Tremors
6. Increasing anxiety✅✅ANSWER✅✅✅1, 3, 5, 6
6.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✅✅ANSWER✅✅✅1, 4, 5
