SATA NCLEX SAUNDERS REVIEW
Rifabutin (Mycobutin) is prescribed for a client with active Mycobacterium avium complex (MAC)
disease and tuberculosis. The nurse monitors for which side effects of the medication? - VERIFIED
ANSWER Signs of hepatitis
Flu-like syndrome
Low neutrophil count
Ocular pain or blurred vision
A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme
dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse
immediately notifies the registered nurse and expects which interventions to be prescribed? - VERIFIED
ANSWER Administering oxygen
Inserting a Foley catheter
Administering furosemide (Lasix)
Administering morphine sulfate intravenously
A client with coronary artery disease complains of substernal chest pain. After checking the client's heart
rate and blood pressure, a nurse administers nitroglycerin, 0.4 mg, sublingually. After 5 minutes, the
client states, "My chest still hurts." Select the appropriate actions that the nurse should take. - VERIFIED
ANSWER Assess the client's pain level.
Check the client's blood pressure.
Administer a second nitroglycerin, 0.4 mg, sublingually.
Contact the registered nurse.
The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the
inflow. The nurse should take which actions? - VERIFIED ANSWER Check the level of the drainage bag.
Reposition the client to his or her side.
Place the client in good body alignment.
,Check the peritoneal dialysis system for kinks.
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? - VERIFIED ANSWER To avoid
activities that require bending over
To place an eye shield on the surgical eye at bedtime
To contact the surgeon if a decrease in visual acuity occurs
To take acetaminophen (Tylenol) for minor eye discomfort
The nurse is preparing to administer eye drops. Select the interventions that the nurse takes to
administer the drops - VERIFIED ANSWER Wash hands.
Put on gloves.
Place the drop in the conjunctival sac.
Pull the lower lid down against the cheek bone.
A client is receiving meperidine hydrochloride (Demerol) for pain. Which of the following are side effects
of this medication - VERIFIED ANSWER Hypotension
Tremors
Drowsiness
A nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his
right forearm. Which instructions should the nurse include on the list? - VERIFIED ANSWER Keep the
cast and extremity elevated.
The cast needs to be kept clean and dry.
Allow the wet cast 24 to 72 hours to dry.
A nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his
right forearm. Which instructions should the nurse include on the list? - VERIFIED ANSWER Symptom
control during periods of emotional stress
,Normal white blood cell counts, platelet, and neutrophil counts
Radiological findings that show nonprogression of joint degeneration
An increased range of motion in the affected joints 3 months into therapy
Which interventions would apply in the care of a client at high risk for an allergic response to a latex
allergy. - VERIFIED ANSWER Use non-latex gloves.
Use medications from glass ampules
Keep a latex-safe supply cart available in the client's area.
Do not puncture rubber stoppers with needles
Ketoconazole is prescribed for a client with a diagnosis of candidiasis. Select the interventions that the
nurse includes when administering this medication - VERIFIED ANSWER Monitor hepatic and liver
function studies.
Instruct the client to avoid alcohol.
Instruct the client to avoid exposure to the sun.
A client with human immunodeficiency virus is taking nevirapine (Viramune). The nurse should monitor
for which adverse effects of the medication? - VERIFIED ANSWER Hepatotoxicity
Rash
The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication
techniques with a nursing student. Which of the following are therapeutic communication techniques? -
VERIFIED ANSWER Restating
Listening
Maintaining neutral responses
Providing acknowledgment and feedback
, Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting
manipulative behavior? - VERIFIED ANSWER Assist the client in developing meVERIFIED ANSWER of
setting limits on personal behavior.
Follow through about the consequences of behavior in a nonpunitive manner.
Be clear with the client regarding the consequences of exceeding limits set regarding behavior.
Communicate expected behaviors to the client.
Which of the following are appropriate interventions for caring for the client in alcohol withdrawal -
VERIFIED ANSWER Monitor vital signs.
Provide a safe environment.
Address hallucinations therapeutically.
Provide reality orientation as appropriate.
A nurse is preparing to care for a dying client, and several family members are at the client's bedside.
Which therapeutic techniques should the nurse use when communicating with the family. - VERIFIED
ANSWER Extend touch and hold the client's or family member's hand if appropriate.
Be honest and truthful and let the client and family know that you will not abandon them
Encourage expression of feelings, concerns, and fears.
A hospitalized client is started on phenelzine sulfate (Nardil) for the treatment of depression. The nurse
instructs the client to avoid consuming which foods while taking this medication? - VERIFIED ANSWER
Figs
Yogurt
Aged cheese
A client enters the emergency room confused, twitching, and having seizures. His family states he
recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. Upon
assessment, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin
turgor. His serum sodium level is 172 mEq/L. Choose the interventions that the health care provider
would likely prescribe. - VERIFIED ANSWER Monitor intake and output.
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