NCLEX-RN
Adult Health Med Surg NCLEX Test Bank Questions
Extract:
Question 1 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 2 of 5
A client has an epidural catheter inserted for postoperative pain management. The client rates his pain at 4 on a 0-to-5 pain scale. What should the nurse do first?
Correct Answer: C
Rationale: Assessing vital signs first ensures the client is stable, as a pain level of 4 may indicate complications (e.g., respiratory depression). Checking the pump, adjusting the catheter, or notifying the physician follow if needed.
Question 3 of 5
Which of the following statements would indicate to the nurse that the client who has undergone repair of her nasal septum has understood the discharge instructions?
Correct Answer: B
Rationale: Taking stool softeners and modifying the diet to prevent constipation avoids straining (Valsalva's maneuver), which could cause bleeding or complications post-nasal surgery.
Question 4 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 5 of 5
The client who had an open femoral fracture was discharged to her home where she developed fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg. Which of the following reflects the best interpretation of these findings?
Correct Answer: B
Rationale: These symptoms suggest osteomyelitis, a bone infection common after open fractures.