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Tuesday, September 2, 2008

Nclex Sata (Select All That Applies) Nursing Study Guide 1

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1. The nurse is planning care for a client with hyperthyroidism. Which nursing interventions are appropriate?

Select all that apply: Nclex SATA

1. Instill isotonic eye drops, as necessary.
2. Provide several small, well-balanced meals.
3. Provide rest periods.
4. Keep the environment warm.
5. Encourage frequent visitors and conversation.
6. Weigh the client daily.


2. The nurse is caring for a client with emphysema. Which nursing interventions are appropriate?

Select all that apply: Nclex SATA

1. Reduce fluid intake to less than 2,500 ml/day.
2. Teach diaphragmatic, pursed-lip breathing.
3. Administer low-flow oxygen.
4. Keep the client in a supine position as much as possible.
5. Encourage alternating activity with rest periods.
6. Teach use of postural drainage and chest physiotherapy.

3. The nurse is caring for a client who underwent surgical repair of a detached retina of the right eye. Which interventions should the nurse perform?

Select all that apply: Nclex SATA

1. Place the client in a prone position.
2. Approach the client from the left side.
3. Encourage deep breathing and coughing.
4. Discourage bending down.
5. Orient the client to his environment.
6. Administer a stool softener.

4. The client has a tumor of the posterior pituitary gland. The nurse planning his care should include which interventions?

Select all that apply: Nclex SATA

1. Take daily weight.
2. Restrict fluids.
3. Assess urine specific gravity.
4. Encourage intake of coffee or tea.
5. Monitor intake and output.

5. The nurse is developing a care plan for a client with injury to the frontal lobe of the brain. Which interventions should be part of the care plan?

Select all that apply: Nclex SATA

1. Keep instructions simple and brief because the client will have difficulty concentrating.
2. Speak clearly and slowly because the client will have difficulty hearing.
3. Assist the client with bathing because he will have vision disturbances.
4. Orient the client to person, place, and time as needed because of memory problems.
5. Assess vital signs frequently because vital bodily functions are affected.

6. The nurse is caring for a client whose cultural background is different from her own. Which actions are appropriate?

Select all that apply: Nclex SATA

1. Consider that nonverbal cues, such as eye contact, may have a different meaning in different cultures.
2. Respect the client's cultural beliefs.
3. Ask the client if he has cultural or religious requirements that should be considered in his care.
4. Explain the nurse's beliefs so that the client will understand the differences.
5. Understand that all cultures experience pain in the same way.

7. A 62-year-old client has just been diagnosed with terminal cancer and is being transferred to home hospice care. The client's daughter tells the nurse, "I don't know what to say to my mother if she asks me if she's going to die." Which of the following responses by the nurse would be appropriate?

Select all that apply: Nclex SATA

1. "Don't worry, your mother still has some time left."
2. "Let's talk about your mother's illness and how it will progress."
3. "You sound like you have some questions about your mother dying. Let's talk about that."
4. "Don't worry, hospice will take care of your mother."
5. "Tell me how you're feeling about your mother dying."

8. A 62-year-old client has just been diagnosed with terminal cancer and is being transferred to home hospice care. The client's daughter tells the nurse, "I don't know what to say to my mother if she asks me if she's going to die." Which of the following responses by the nurse would be appropriate?

Select all that apply: Nclex SATA

1. "Don't worry, your mother still has some time left."
2. "Let's talk about your mother's illness and how it will progress."
3. "You sound like you have some questions about your mother dying. Let's talk about that."
4. "Don't worry, hospice will take care of your mother."
5. "Tell me how you're feeling about your mother dying."

9. While providing care to a 26-year-old married female, the nurse notes multiple ecchymotic areas on her arms and trunk. The color of the ecchymotic areas ranges from blue to purple to yellow. When asked by the nurse how she got these bruises, the client responds, "Oh, I tripped." How should the nurse respond?

Select all that apply: Nclex SATA

1. Document the client's statement and complete a body map indicating the size, color, shape, location, and type of injuries.
2. Report suspicions of abuse to the local authorities.
3. Assist the client in developing a safety plan for times of increased violence.
4. Call the client's husband to discuss the situation.
5. Tell the client that she needs to leave the abusive situation as soon as possible.
6. Provide the client with telephone numbers of local shelters and safe houses.

10. A nurse is working with the family of a client who has Alzheimer's disease. The nurse notes that the client's spouse is too exhausted to continue providing care all alone. The adult children live too far away to provide relief on a weekly basis. Which nursing interventions would be most helpful?

Select all that apply: Nclex SATA

1. Calling a family meeting to tell the absent children that they must participate in helping the client
2. Suggesting the spouse seek psychological counseling to help cope with exhaustion
3. Recommending community resources for adult day care and respite care
4. Encouraging the spouse to talk about the difficulties involved in caring for a loved one with Alzheimer's disease
5. Asking whether friends or church members can help with errands or provide short periods of relief
6. Recommending that the client be placed in a long-term care facilityle.


Nclex SATA Nursing Study Guide 1 Answers

1. Answer: 1, 2, 3, 6
2. Answer: 2, 3, 5, 6
3. Answer: 2, 4, 5, 6
4. Answer: 1, 3, 5
5. Answer: 1, 4
6. Answer: 1, 2, 3
7. Answer: 2, 3, 5
8. Answer: 1, 2, 4
9. Answer: 1, 3, 6
10. Answer: 3, 4, 5








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