NGN NCLEX RN SATA ACTUAL EXAM |
LATEST EXAM QUESTIONS AND
ANSWERS | DETAILED ANSWERS |
GRADED A+
1. A nurse is collecting data on a client with severe preeclampsia. Choose the findings
that would be noted in severe preeclampsia. Select all that apply.
1. Oliguria
2. Seizures
3. Contractions
4. Proteinuria 3+
5. Muscle cramps
6. Blood pressure 168/116 mm Hg -----CORRECT ANSWER------------16. Answers: 1,
4, and 6.Severe preeclampsia is characterized by blood pressure higher than
160/110 mm Hg, proteinuria 3+ or higher, and oliguria. Seizures (convulsions) are
present in eclampsia and are not a characteristic of severe preeclampsia. Muscle
cramps and contractions are not findings noted in severe preeclampsia, although
the client is monitored for these occurrences.
2. A nurse is monitoring a client with Graves' disease for signs of thyrotoxicosis (thyroid
storm). Which of the following signs and symptoms, if noted in the client, will alert the
nurse to the presence of this crisis? Select all that apply.
1. Bradycardia
2. Fever
3. Sweating
4. Agitation
5. Pallor -----CORRECT ANSWER------------17. Answers: 2, 3, and 4.Thyrotoxic crisis
(thyroid storm) is an acute, potentially life-threatening state of extreme thyroid
activity that represents a breakdown in the body's tolerance to a chronic excess
of thyroid hormones. The clinical manifestations include fever greater than 100°
F, severe tachycardia, flushing and sweating, and marked agitation and
restlessness. Delirium and coma can occur.
3. A nurse is monitoring a group of clients for acid-base imbalances. Which clients are
at highest risk for metabolic acidosis? Select all that apply.
1. Severely anxious client
2. Pneumonia client
3. Diabetic mellitus client
,4. Malnourished client
5. Asthma client
6. Renal failure client -----CORRECT ANSWER------------18. Answers: 3, 4, and
6.Diabetes mellitus, malnutrition, and renal failure lead to metabolic acidosis
because of the increasing acids in the body. Options 1, 2, and 5 are respiratory
problems, not metabolic, and result in either respiratory acidosis or respiratory
alkalosis.
4. The nurse is preparing a teaching plan for a client who is undergoing cataract
extraction with intraocular implant. Which home care measures will the nurse include in
the plan? Select all that apply.
1. To avoid activities that require bending over
2. To contact the surgeon if eye scratchiness occurs
3. To place an eye shield on the surgical eye at bedtime
4. That episodes of sudden severe pain in the eye is expected
5. To contact the surgeon if a decrease in visual acuity occurs
6. To take acetaminophen (Tylenol) for minor eye discomfort -----CORRECT ANSWER-
-----------19. Answers: 1, 3, 5, and 6.After eye surgery, some scratchiness and mild
eye discomfort may occur in the operative eye and is usually relieved by mild
analgesics. If the eye pain becomes severe, the client should notify the surgeon
because this may indicate hemorrhage, infection, or increased intraocular
pressure. The nurse would also instruct the client to notify the surgeon of
purulent drainage, increased redness, or any decrease in visual acuity. The client
is instructed to place an eye shield over the operative eye at bedtime to protect
the eye from injury during sleep and to avoid activities that increase intraocular
pressure such as bending over.
6. 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.
1. Partial thromboplastin time.
2. Prothrombin time.
3. Platelet count.
4. Hemoglobin
5. Complete Blood Count
6. White Blood Cell Count -----CORRECT ANSWER------------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.
7. 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.
,1. Weight loss.
2. Increased clotting time.
3. Hypertension.
4. Headaches. -----CORRECT ANSWER------------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.
8. 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.
1. The inhaler is held upright.
2. Head is tilted down while inhaling the medication
3. Client waits 5 minutes between puffs.
4. Mouth is rinsed with water following administration
5. Client lies supine for 15 minutes following administration. -----CORRECT ANSWER---
---------3. Answer: 1 and 4.
9. 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.
1. Hearing loss
2. Visual disturbance
3. Headache
4. Orthopnea5. Gout6. Weight loss -----CORRECT ANSWER------------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.
10. Which of the following would be priority assessment data to gather from a client who
has been diagnosed with pneumonia? Select all that apply.
1. Auscultation of breath sounds2. Auscultation of bowel sounds3. Presence of chest
pain.4. Presence of peripheral edema5. Color of nail beds -----CORRECT ANSWER-----
-------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.
11. 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.
1. "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." -----CORRECT
ANSWER------------6. Answer: 2, 4, 5.
12. The nurse is admitting a client with hypoglycemia. Identify the signs and symptoms
the nurse should expect. Select all that apply.
1. Thirst
2. Palpitations
3. Diaphoresis
4. Slurred speech
5. Hyperventilation -----CORRECT ANSWER------------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.
13. Which adaptations should the nurse caring for a client with diabetic ketoacidosis
expect the client to exhibit? Select all that apply:
1. Sweating
2. Low PCO2
3. Retinopathy
4. Acetone breath
5. Elevated serum bicarbonate -----CORRECT ANSWER------------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.
LATEST EXAM QUESTIONS AND
ANSWERS | DETAILED ANSWERS |
GRADED A+
1. A nurse is collecting data on a client with severe preeclampsia. Choose the findings
that would be noted in severe preeclampsia. Select all that apply.
1. Oliguria
2. Seizures
3. Contractions
4. Proteinuria 3+
5. Muscle cramps
6. Blood pressure 168/116 mm Hg -----CORRECT ANSWER------------16. Answers: 1,
4, and 6.Severe preeclampsia is characterized by blood pressure higher than
160/110 mm Hg, proteinuria 3+ or higher, and oliguria. Seizures (convulsions) are
present in eclampsia and are not a characteristic of severe preeclampsia. Muscle
cramps and contractions are not findings noted in severe preeclampsia, although
the client is monitored for these occurrences.
2. A nurse is monitoring a client with Graves' disease for signs of thyrotoxicosis (thyroid
storm). Which of the following signs and symptoms, if noted in the client, will alert the
nurse to the presence of this crisis? Select all that apply.
1. Bradycardia
2. Fever
3. Sweating
4. Agitation
5. Pallor -----CORRECT ANSWER------------17. Answers: 2, 3, and 4.Thyrotoxic crisis
(thyroid storm) is an acute, potentially life-threatening state of extreme thyroid
activity that represents a breakdown in the body's tolerance to a chronic excess
of thyroid hormones. The clinical manifestations include fever greater than 100°
F, severe tachycardia, flushing and sweating, and marked agitation and
restlessness. Delirium and coma can occur.
3. A nurse is monitoring a group of clients for acid-base imbalances. Which clients are
at highest risk for metabolic acidosis? Select all that apply.
1. Severely anxious client
2. Pneumonia client
3. Diabetic mellitus client
,4. Malnourished client
5. Asthma client
6. Renal failure client -----CORRECT ANSWER------------18. Answers: 3, 4, and
6.Diabetes mellitus, malnutrition, and renal failure lead to metabolic acidosis
because of the increasing acids in the body. Options 1, 2, and 5 are respiratory
problems, not metabolic, and result in either respiratory acidosis or respiratory
alkalosis.
4. The nurse is preparing a teaching plan for a client who is undergoing cataract
extraction with intraocular implant. Which home care measures will the nurse include in
the plan? Select all that apply.
1. To avoid activities that require bending over
2. To contact the surgeon if eye scratchiness occurs
3. To place an eye shield on the surgical eye at bedtime
4. That episodes of sudden severe pain in the eye is expected
5. To contact the surgeon if a decrease in visual acuity occurs
6. To take acetaminophen (Tylenol) for minor eye discomfort -----CORRECT ANSWER-
-----------19. Answers: 1, 3, 5, and 6.After eye surgery, some scratchiness and mild
eye discomfort may occur in the operative eye and is usually relieved by mild
analgesics. If the eye pain becomes severe, the client should notify the surgeon
because this may indicate hemorrhage, infection, or increased intraocular
pressure. The nurse would also instruct the client to notify the surgeon of
purulent drainage, increased redness, or any decrease in visual acuity. The client
is instructed to place an eye shield over the operative eye at bedtime to protect
the eye from injury during sleep and to avoid activities that increase intraocular
pressure such as bending over.
6. 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.
1. Partial thromboplastin time.
2. Prothrombin time.
3. Platelet count.
4. Hemoglobin
5. Complete Blood Count
6. White Blood Cell Count -----CORRECT ANSWER------------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.
7. 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.
,1. Weight loss.
2. Increased clotting time.
3. Hypertension.
4. Headaches. -----CORRECT ANSWER------------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.
8. 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.
1. The inhaler is held upright.
2. Head is tilted down while inhaling the medication
3. Client waits 5 minutes between puffs.
4. Mouth is rinsed with water following administration
5. Client lies supine for 15 minutes following administration. -----CORRECT ANSWER---
---------3. Answer: 1 and 4.
9. 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.
1. Hearing loss
2. Visual disturbance
3. Headache
4. Orthopnea5. Gout6. Weight loss -----CORRECT ANSWER------------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.
10. Which of the following would be priority assessment data to gather from a client who
has been diagnosed with pneumonia? Select all that apply.
1. Auscultation of breath sounds2. Auscultation of bowel sounds3. Presence of chest
pain.4. Presence of peripheral edema5. Color of nail beds -----CORRECT ANSWER-----
-------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.
11. 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.
1. "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." -----CORRECT
ANSWER------------6. Answer: 2, 4, 5.
12. The nurse is admitting a client with hypoglycemia. Identify the signs and symptoms
the nurse should expect. Select all that apply.
1. Thirst
2. Palpitations
3. Diaphoresis
4. Slurred speech
5. Hyperventilation -----CORRECT ANSWER------------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.
13. Which adaptations should the nurse caring for a client with diabetic ketoacidosis
expect the client to exhibit? Select all that apply:
1. Sweating
2. Low PCO2
3. Retinopathy
4. Acetone breath
5. Elevated serum bicarbonate -----CORRECT ANSWER------------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.
