1. 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?: Signs of hepatitis
Flu-like syndrome
Low neutrophil count
Ocular pain or blurred vision
2. 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?: Administering oxygen
Inserting a Foley catheter
Administering furosemide (Lasix)
Administering morphine sulfate intravenously
3. 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.: Assess the client's pain level.
Check the client's blood pressure.
Administer a second nitroglycerin, 0.4 mg, sublingually.
Contact the registered nurse.
4. 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?: 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.
5. 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?: To avoid activities that require bending over
To place an eye shield on the surgical eye at bedtime
, SATA NCLEX SAUNDERS REVIEW
To contact the surgeon if a decrease in visual acuity occurs
To take acetaminophen (Tylenol) for minor eye discomfort
6. The nurse is preparing to administer eye drops. Select the interventions that the nurse
takes to administer the drops: Wash hands.
Put on gloves.
Place the drop in the conjunctival sac.
Pull the lower lid down against the cheek bone.
7. A client is receiving meperidine hydrochloride (Demerol) for pain. Which of
the following are side effects of this medication: Hypotension Tremors
Drowsiness
8. 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?: 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.
9. 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?: 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
10. Which interventions would apply in the care of a client at high risk for an allergic
response to a latex allergy.: 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
11. Ketoconazole is prescribed for a client with a diagnosis of candidiasis. Select the
interventions that the nurse includes when administering this medication: Monitor
hepatic and liver function studies.
Instruct the client to avoid alcohol.
, SATA NCLEX SAUNDERS REVIEW
Instruct the client to avoid exposure to the sun.
12. A client with human immunodeficiency virus is taking nevirapine (Viramune). The
nurse should monitor for which adverse effects of the medication?: Hepatotoxicity
Rash
13. 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?: Restating Listening
Maintaining neutral responses
Providing acknowledgment and feedback
14. Which nursing interventions are appropriate for a hospitalized client with mania
who is exhibiting manipulative behavior?: Assist the client in developing means 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.
15. Which of the following are appropriate interventions for caring for the client in
alcohol withdrawal: Monitor vital signs.
Provide a safe environment.
Address hallucinations therapeutically.
Provide reality orientation as appropriate.
16. 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.: 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.
, SATA NCLEX SAUNDERS REVIEW
17. 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?: Figs
Yogurt
Aged cheese
18. 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.: Monitor intake and output. Monitor the vital signs.
Monitor the electrolyte levels.
Increase water intake orally.
Provide a sodium-reduced diet.
19. A nurse is preparing to suction an adult client through the client's tracheostomy
tube. Which intervention(s) would the nurse perform for this procedure?: Apply
intermittent suction while rotating and withdrawing the catheter.
Advance the catheter until resistance is met and then pull the catheter back 1 cm.
Apply suction for up to 10 to 15 seconds.
Hyperoxygenate the client before suctioning.
20. Which of these clients are most likely to develop fluid (circulatory) overload?: A
premature infant
A 101-year-old man
A client on renal dialysis
A client with congestive heart failure
21. A nurse is assisting with planning care for a client with an internal radiation
implant. Which of the following should be included in the plan of care?: Wearing gloves
when emptying the client's bedpan
Keeping all linens in the room until the implant is removed
Wearing a film (dosimeter) badge when in the client's room
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