NCLEX RN SATA
QUESTIONS AND
ANSWERS WITH
RATIONALES PASSING IS
GUARANTEED 2024
Question 1
A nurse is caring for a patient diagnosed with heart failure. Which of the following assessments
should the nurse perform? Select all that apply.
1. Monitor daily weight.
2. Assess lung sounds.
3. Check peripheral pulses.
4. Measure blood glucose levels.
5. Evaluate the patient’s fluid intake and output.
Answers: 1, 2, 3, 5
Rationale:
● 1. Monitor daily weight: Important to assess fluid retention or loss.
● 2. Assess lung sounds: Can indicate fluid accumulation in the lungs.
● 3. Check peripheral pulses: Important for assessing circulation and perfusion.
● 5. Evaluate the patient’s fluid intake and output: Essential for managing fluid balance
in heart failure.
● 4. Measure blood glucose levels: Not typically a priority for heart failure unless the
patient has diabetes.
Question 2
,The nurse is teaching a group of nursing students about infection control. Which of the following
statements indicate a need for further teaching? Select all that apply.
1. “I can wash my hands with plain soap for any situation.”
2. “I should use alcohol-based hand sanitizer before entering a patient’s room.”
3. “Gloves should be worn for all patient interactions.”
4. “Hand hygiene should be performed after removing gloves.”
5. “Surgical masks are sufficient for airborne precautions.”
Answers: 1, 3, 5
Rationale:
● 1. “I can wash my hands with plain soap for any situation.”: Plain soap is not
adequate for all situations; antimicrobial soap is preferred in many cases.
● 3. “Gloves should be worn for all patient interactions.”: Gloves should be worn
based on the situation and type of interaction, not universally.
● 5. “Surgical masks are sufficient for airborne precautions.”: N95 respirators are
required for airborne precautions, not surgical masks.
● 2. “I should use alcohol-based hand sanitizer before entering a patient’s room.”:
This is correct; it is effective for most situations.
● 4. “Hand hygiene should be performed after removing gloves.”: This is correct;
hand hygiene is necessary after glove removal to prevent cross-contamination.
Question 3
A nurse is caring for a client with a newly diagnosed diabetes mellitus. Which statements made
by the client indicate a need for further teaching? Select all that apply.
1. “I can eat whatever I want as long as I take my medication.”
2. “I should check my blood glucose levels every morning.”
3. “I will increase my exercise if my blood sugar is high.”
4. “It’s okay to skip meals if I’m not hungry.”
5. “I can consume fruit juices as a substitute for whole fruits.”
Answers: 1, 4, 5
Rationale:
● 1. “I can eat whatever I want as long as I take my medication.”: This is incorrect;
dietary management is crucial in diabetes care.
● 4. “It’s okay to skip meals if I’m not hungry.”: Skipping meals can lead to unstable
blood glucose levels.
● 5. “I can consume fruit juices as a substitute for whole fruits.”: Fruit juices are often
high in sugar and should be consumed in moderation compared to whole fruits.
● 2. “I should check my blood glucose levels every morning.”: This is correct; regular
monitoring is essential.
● 3. “I will increase my exercise if my blood sugar is high.”: This is correct; exercise
can help lower blood glucose levels.
, Question 4
A nurse is preparing to discharge a patient after a cholecystectomy. Which of the following
statements indicate the patient needs further teaching? Select all that apply.
1. “I can eat fried foods as soon as I feel ready.”
2. “I should avoid heavy lifting for a few weeks.”
3. “I will monitor my incision for signs of infection.”
4. “I can resume driving when I feel comfortable.”
5. “I need to start taking my cholesterol medication right away.”
Answers: 1, 5
Rationale:
● 1. “I can eat fried foods as soon as I feel ready.”: Fried foods should be avoided after
gallbladder removal due to difficulty digesting fats.
● 5. “I need to start taking my cholesterol medication right away.”: While cholesterol
management may be necessary, this statement may need further discussion with the
healthcare provider.
● 2. “I should avoid heavy lifting for a few weeks.”: Correct; avoiding heavy lifting aids
in recovery.
● 3. “I will monitor my incision for signs of infection.”: Correct; incision care is
essential.
● 4. “I can resume driving when I feel comfortable.”: Correct; this is generally allowed
as long as the patient is not taking narcotics that impair driving.
Question 5
A nurse is assessing a patient with a history of chronic obstructive pulmonary disease (COPD).
Which findings would indicate a need for immediate intervention? Select all that apply.
1. Increased use of accessory muscles during respiration.
2. Oxygen saturation of 92%.
3. Wheezing upon auscultation.
4. Cyanosis of the lips and fingertips.
5. Heart rate of 90 beats per minute.
Answers: 1, 4
Rationale:
● 1. Increased use of accessory muscles during respiration: Indicates respiratory
distress and requires immediate attention.
● 4. Cyanosis of the lips and fingertips: This is a sign of severe hypoxia and
necessitates immediate intervention.
● 2. Oxygen saturation of 92%: While slightly low, it is not an emergency unless
accompanied by other distress signs.
QUESTIONS AND
ANSWERS WITH
RATIONALES PASSING IS
GUARANTEED 2024
Question 1
A nurse is caring for a patient diagnosed with heart failure. Which of the following assessments
should the nurse perform? Select all that apply.
1. Monitor daily weight.
2. Assess lung sounds.
3. Check peripheral pulses.
4. Measure blood glucose levels.
5. Evaluate the patient’s fluid intake and output.
Answers: 1, 2, 3, 5
Rationale:
● 1. Monitor daily weight: Important to assess fluid retention or loss.
● 2. Assess lung sounds: Can indicate fluid accumulation in the lungs.
● 3. Check peripheral pulses: Important for assessing circulation and perfusion.
● 5. Evaluate the patient’s fluid intake and output: Essential for managing fluid balance
in heart failure.
● 4. Measure blood glucose levels: Not typically a priority for heart failure unless the
patient has diabetes.
Question 2
,The nurse is teaching a group of nursing students about infection control. Which of the following
statements indicate a need for further teaching? Select all that apply.
1. “I can wash my hands with plain soap for any situation.”
2. “I should use alcohol-based hand sanitizer before entering a patient’s room.”
3. “Gloves should be worn for all patient interactions.”
4. “Hand hygiene should be performed after removing gloves.”
5. “Surgical masks are sufficient for airborne precautions.”
Answers: 1, 3, 5
Rationale:
● 1. “I can wash my hands with plain soap for any situation.”: Plain soap is not
adequate for all situations; antimicrobial soap is preferred in many cases.
● 3. “Gloves should be worn for all patient interactions.”: Gloves should be worn
based on the situation and type of interaction, not universally.
● 5. “Surgical masks are sufficient for airborne precautions.”: N95 respirators are
required for airborne precautions, not surgical masks.
● 2. “I should use alcohol-based hand sanitizer before entering a patient’s room.”:
This is correct; it is effective for most situations.
● 4. “Hand hygiene should be performed after removing gloves.”: This is correct;
hand hygiene is necessary after glove removal to prevent cross-contamination.
Question 3
A nurse is caring for a client with a newly diagnosed diabetes mellitus. Which statements made
by the client indicate a need for further teaching? Select all that apply.
1. “I can eat whatever I want as long as I take my medication.”
2. “I should check my blood glucose levels every morning.”
3. “I will increase my exercise if my blood sugar is high.”
4. “It’s okay to skip meals if I’m not hungry.”
5. “I can consume fruit juices as a substitute for whole fruits.”
Answers: 1, 4, 5
Rationale:
● 1. “I can eat whatever I want as long as I take my medication.”: This is incorrect;
dietary management is crucial in diabetes care.
● 4. “It’s okay to skip meals if I’m not hungry.”: Skipping meals can lead to unstable
blood glucose levels.
● 5. “I can consume fruit juices as a substitute for whole fruits.”: Fruit juices are often
high in sugar and should be consumed in moderation compared to whole fruits.
● 2. “I should check my blood glucose levels every morning.”: This is correct; regular
monitoring is essential.
● 3. “I will increase my exercise if my blood sugar is high.”: This is correct; exercise
can help lower blood glucose levels.
, Question 4
A nurse is preparing to discharge a patient after a cholecystectomy. Which of the following
statements indicate the patient needs further teaching? Select all that apply.
1. “I can eat fried foods as soon as I feel ready.”
2. “I should avoid heavy lifting for a few weeks.”
3. “I will monitor my incision for signs of infection.”
4. “I can resume driving when I feel comfortable.”
5. “I need to start taking my cholesterol medication right away.”
Answers: 1, 5
Rationale:
● 1. “I can eat fried foods as soon as I feel ready.”: Fried foods should be avoided after
gallbladder removal due to difficulty digesting fats.
● 5. “I need to start taking my cholesterol medication right away.”: While cholesterol
management may be necessary, this statement may need further discussion with the
healthcare provider.
● 2. “I should avoid heavy lifting for a few weeks.”: Correct; avoiding heavy lifting aids
in recovery.
● 3. “I will monitor my incision for signs of infection.”: Correct; incision care is
essential.
● 4. “I can resume driving when I feel comfortable.”: Correct; this is generally allowed
as long as the patient is not taking narcotics that impair driving.
Question 5
A nurse is assessing a patient with a history of chronic obstructive pulmonary disease (COPD).
Which findings would indicate a need for immediate intervention? Select all that apply.
1. Increased use of accessory muscles during respiration.
2. Oxygen saturation of 92%.
3. Wheezing upon auscultation.
4. Cyanosis of the lips and fingertips.
5. Heart rate of 90 beats per minute.
Answers: 1, 4
Rationale:
● 1. Increased use of accessory muscles during respiration: Indicates respiratory
distress and requires immediate attention.
● 4. Cyanosis of the lips and fingertips: This is a sign of severe hypoxia and
necessitates immediate intervention.
● 2. Oxygen saturation of 92%: While slightly low, it is not an emergency unless
accompanied by other distress signs.
