NCLEX-RN
Adult Health Med Surg NCLEX Test Bank Questions
Extract:
Question 1 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 2 of 5
A client has an amylase level of 450 units/L and lipase level of 659 units/L. The client has mid-epigastric pain with nausea. What assessment helps the nurse to determine severity of the client's condition?
Correct Answer: A
Rationale: Ranson's criteria (
A) assess pancreatitis severity using clinical and lab parameters like age, glucose, and white blood cell count. Vital signs (
B) and urine output (
C) are general but less specific. Glasgow Coma Scale (
D) is for neurological assessment, not pancreatitis severity.
Question 3 of 5
The nurse prepares a teaching plan for a client about crutch walking using a two-point gait pattern. Which of the following should the nurse include?
Correct Answer: B
Rationale: The two-point gait involves simultaneous advancement of one crutch and the opposite foot, mimicking natural walking.
Question 4 of 5
The nurse is assessing a client for movement after halo traction placement for a C8 fracture. The nurse should document which of the following?
Correct Answer: A
Rationale: A C8 fracture affects the lower cervical nerves, but shoulder shrug (trapezius, innervated by cranial nerve XI and C3-C4) should remain intact. Arm movements and hand grasp involve C5-C8 and may be impaired, making shoulder shrug the most reliable intact movement to document.
Question 5 of 5
The nurse should assess the client with Ménière'sdisease for the intended outcomes of which of the following medications that are commonly used to manage the disease? Select all that apply.
Correct Answer: A,B,C
Rationale: Common medications for Ménière'sdisease include antihistamines (e.g., meclizine) to reduce vertigo, antiemetics to control nausea, and diuretics to reduce inner ear fluid, all aimed at symptom management.