NCLEX-RN
Adult Health Med Surg NCLEX Test Bank Questions
Extract:
Question 1 of 5
The nurse administers fat emulsion solution during TPN as ordered based on the understanding that this type of solution:
Correct Answer: A
Rationale: Fat emulsion solutions in TPN provide essential fatty acids to prevent deficiency. They do not primarily provide carbohydrates, promote glucose metabolism, or maintain body weight. CN: Pharmacological and parenteral therapies; CL: Apply
Question 2 of 5
There is a shooting in a shopping mall. Three victims with gunshot wounds are brought to the emergency department. What should the nurse do to preserve forensic evidence? Select all that apply.
Correct Answer: B
Rationale:
To preserve forensic evidence, clothing should be placed in separate paper bags to prevent cross-contamination. Cutting around blood stains or placing bullets in sterile containers may damage evidence, and documentation of statements is necessary for legal purposes.
Question 3 of 5
The nurse is observing a student nurse administer eyedrops, as shown in the figure. What should the nurse instruct the student to do?
Correct Answer: C
Rationale: The student has positioned the dropper and the client correctly to prevent injury to the client's eye. The student should administer the drops in the center of the lower lid. Following administration of the eyedrops, the client should blink her eyes to distribute the medication; squeezing or rubbing her eyes might cause the medication to drip out of the eye.
Question 4 of 5
A client with terminal cancer expresses fear of dying alone. The nurse's most therapeutic response is:
Correct Answer: A
Rationale: Assuring the client that someone will be present addresses their fear directly, providing emotional reassurance and support.
Question 5 of 5
The nurse is caring for a client who has just had an ankle-brachial index (ABI) test. The left arm blood pressure was 160/80 mm Hg and a palpable systolic blood pressure of the left lower extremity was 130/60 mm Hg. These findings suggest that the client has:
Correct Answer: A
Rationale: ABI = ankle systolic BP ÷ arm systolic BP = 130 ÷ 160 = 0.81. An ABI of 0.8–0.9 indicates mild peripheral artery disease, suggesting some arterial narrowing. Normal ABI is 0.9–1.3, moderate is 0.5–0.8, and severe is <0.5.