NCLEX SATA Questions And Correct Verified Answers With Rationales (Select
All That Apply)
Instructions: Select all answers that apply. Answers and rationales are provided after each question.
1. Heart Failure
A nurse is caring for a clientwith heart failure. Which findings indicate fluid overload?
A.Jugular vein distention
B. Weight gain of 3 lb in 24 hours
C.Bradycardia
D. Crackles in lungs
E.Peripheral edema
Answer: A, B, D,E
Rationale: Fluid overload causes JVD, rapid weight gain, crackles, and edema. Bradycardia is not a typical
sign; tachycardia is more common.
2. Hyperkalemia
Which manifestations are expected in aclient with hyperkalemia?
A.Muscle weakness
B.Peaked T waves
C.Hypoactive reflexes
D. Ventricular dysrhythmias
E.Constipation
Answer:A, B, C,D
Rationale: Hyperkalemia affects cardiac and neuromuscular function, causing muscle
weakness,decreased reflexes, peaked T waves, and dysrhythmias.
3. Hypoglycemia
Which signs indicate hypoglycemia?
A.Diaphoresis
B. Tremors
C.Confusion
D. Polyuria
E. Tachycardia
Answer: A, B, C,E
,Rationale: Adrenergic symptoms include sweating, tremors, and tachycardia. Neuro symptoms
include confusion.
4. Warfarin Therapy
Which findings should the nurse report immediately in a client taking warfarin?
A.Black stools
B. Hematuria
C.INR of 2.5
D. Epistaxis
E.Bruising
Answer: A, B, D,E
Rationale: These findings suggest bleeding. INR 2.5 is therapeutic for many conditions.
5. Increased Intracranial Pressure
Which findings suggest increased ICP?
A.Projectile vomiting
B.Decreased level of consciousness
C. Bradycardia
D. Hypotension
E. Dilated pupil
Answer:A, B, C, E
Rationale: Signs include vomiting, LOC changes, bradycardia,and pupil changes. Hypertension-not
hypotension-is expected.
6. COPD Teaching
Which statements inddicate understanding of COPD management?
A. "I will use pursed-lip breathing."
B. "I should quit smoking."
C. "I will drink plenty of fluids."
D. "I should limit all physical activity."
E. "I will get influenza vaccines."
Answer:A, B,C,E
Rationale: These measures improve airway clearance and reduce exacerbations.
, 7. Digoxin Toxicity
Which findings indicate digoxin toxicity?
A. Nausea
B.Yellow vision
C. Bradycardia
D. Hypertension
E.Vomiting
Answer:A, B, C, E
Rationale: Digoxin toxicity commonly causes GI symptoms, visual disturbances, and bradycardia.
8. Nephrotic Syndrome
Which findings are expected?
A.Massive proteinuria
B. Generalized edema
C. Hypoalbuminemia
D.Hyperlipidemia
E.Hemoconcentration
Answer:A, B, C,D
Rationale: Nephrotic syndrome is characterized by protein loss, edema, low albumin, and elevated
lipids.
9. Contact Precautions
The nurse is caring for a client with MRSA. Which actions are appropriate?
A.Wear gloves
B.Wear gown
C.Hand hygiene before entry
D. Place client in private room
E.Wear N95 mask
Answer:A,B, C,D
Rationale: Contact precautions require gloves, gown, hand hygiene, and preferably a private room.
10. Addison Disease
Which findings are expected?
All That Apply)
Instructions: Select all answers that apply. Answers and rationales are provided after each question.
1. Heart Failure
A nurse is caring for a clientwith heart failure. Which findings indicate fluid overload?
A.Jugular vein distention
B. Weight gain of 3 lb in 24 hours
C.Bradycardia
D. Crackles in lungs
E.Peripheral edema
Answer: A, B, D,E
Rationale: Fluid overload causes JVD, rapid weight gain, crackles, and edema. Bradycardia is not a typical
sign; tachycardia is more common.
2. Hyperkalemia
Which manifestations are expected in aclient with hyperkalemia?
A.Muscle weakness
B.Peaked T waves
C.Hypoactive reflexes
D. Ventricular dysrhythmias
E.Constipation
Answer:A, B, C,D
Rationale: Hyperkalemia affects cardiac and neuromuscular function, causing muscle
weakness,decreased reflexes, peaked T waves, and dysrhythmias.
3. Hypoglycemia
Which signs indicate hypoglycemia?
A.Diaphoresis
B. Tremors
C.Confusion
D. Polyuria
E. Tachycardia
Answer: A, B, C,E
,Rationale: Adrenergic symptoms include sweating, tremors, and tachycardia. Neuro symptoms
include confusion.
4. Warfarin Therapy
Which findings should the nurse report immediately in a client taking warfarin?
A.Black stools
B. Hematuria
C.INR of 2.5
D. Epistaxis
E.Bruising
Answer: A, B, D,E
Rationale: These findings suggest bleeding. INR 2.5 is therapeutic for many conditions.
5. Increased Intracranial Pressure
Which findings suggest increased ICP?
A.Projectile vomiting
B.Decreased level of consciousness
C. Bradycardia
D. Hypotension
E. Dilated pupil
Answer:A, B, C, E
Rationale: Signs include vomiting, LOC changes, bradycardia,and pupil changes. Hypertension-not
hypotension-is expected.
6. COPD Teaching
Which statements inddicate understanding of COPD management?
A. "I will use pursed-lip breathing."
B. "I should quit smoking."
C. "I will drink plenty of fluids."
D. "I should limit all physical activity."
E. "I will get influenza vaccines."
Answer:A, B,C,E
Rationale: These measures improve airway clearance and reduce exacerbations.
, 7. Digoxin Toxicity
Which findings indicate digoxin toxicity?
A. Nausea
B.Yellow vision
C. Bradycardia
D. Hypertension
E.Vomiting
Answer:A, B, C, E
Rationale: Digoxin toxicity commonly causes GI symptoms, visual disturbances, and bradycardia.
8. Nephrotic Syndrome
Which findings are expected?
A.Massive proteinuria
B. Generalized edema
C. Hypoalbuminemia
D.Hyperlipidemia
E.Hemoconcentration
Answer:A, B, C,D
Rationale: Nephrotic syndrome is characterized by protein loss, edema, low albumin, and elevated
lipids.
9. Contact Precautions
The nurse is caring for a client with MRSA. Which actions are appropriate?
A.Wear gloves
B.Wear gown
C.Hand hygiene before entry
D. Place client in private room
E.Wear N95 mask
Answer:A,B, C,D
Rationale: Contact precautions require gloves, gown, hand hygiene, and preferably a private room.
10. Addison Disease
Which findings are expected?
