NCLEX-PN
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1. Which of the following foods is a complete protein?
- A. corn
- B. eggs
- C. peanuts
- D. sunflower seeds
Correct answer: B
Rationale: The correct answer is 'eggs.' Eggs are considered a complete protein as they contain all nine essential amino acids required by the body. On the other hand, corn, peanuts, and sunflower seeds are incomplete proteins, meaning they lack one or more of the essential amino acids needed by the body for optimal health. Corn, peanuts, and sunflower seeds are plant-based proteins that are deficient in one or more essential amino acids, unlike eggs, which are a high-quality complete protein source.
2. How often should the intravenous tubing on total parenteral nutrition solutions be changed?
- A. every 24 hours
- B. every 36 hours
- C. every 48 hours
- D. every 72 hours
Correct answer: A
Rationale: The correct answer is to change the intravenous tubing on total parenteral nutrition solutions every 24 hours. This frequency is necessary due to the high risk of bacterial growth associated with TPN solutions. Changing the tubing every 24 hours helps prevent contamination and bloodstream infections. Choices B, C, and D are incorrect because waiting longer intervals increases the risk of introducing harmful bacteria into the patient's system, leading to potentially severe complications.
3. When testing the function of the oculomotor, trochlear, and abducens nerves, which parameter does a nurse check to determine their function?
- A. Tongue symmetry
- B. Eye movements
- C. Facial symmetry
- D. Corneal reflex
Correct answer: B
Rationale: The correct answer is B: Eye movements. When assessing the oculomotor, trochlear, and abducens nerves, evaluating eye movements is crucial. This assessment includes checking the pupils for size, regularity, equality, light reactions, accommodation, and extraocular movements in various gaze positions. Tongue symmetry is primarily used to evaluate cranial nerve XII (hypoglossal nerve) function. Facial symmetry is a key indicator of cranial nerve VII (facial nerve) function. The corneal reflex assesses sensory afferents in cranial nerve V (trigeminal nerve) and motor efferents in cranial nerve VII (facial nerve).
4. A client is brought to the emergency department after a motor vehicle accident. The client is alert and cooperative but has sustained multiple fractures of the legs. How should the nurse proceed with data collection?
- A. Collect health history information first while initiating emergency measures.
- B. Ask health history questions while performing the examination and initiating emergency measures.
- C. Collect all information requested on the history form, including social support, strengths, and coping patterns.
- D. Perform emergency measures and delay health history questions until after treating the fractures in the operating room.
Correct answer: B
Rationale: When a client is alert and cooperative but has sustained multiple fractures, the nurse should prioritize obtaining health history information while performing the examination and initiating emergency measures. This approach allows the nurse to gather essential information without delaying immediate interventions. Option A is incorrect because collecting health history information before addressing the immediate need for treatment may lead to a delay in necessary interventions. Option C is incorrect as it includes non-urgent aspects of data collection that are not a priority in this critical situation. Option D is incorrect because delaying health history questions until after treating the fractures may result in missing crucial information essential for the client's immediate care.
5. A 2-year-old child diagnosed with HIV comes to a clinic for immunizations. Which of the following vaccines should the healthcare provider expect to administer in addition to the scheduled vaccines?
- A. pneumococcal vaccine
- B. hepatitis A vaccine
- C. Lyme disease vaccine
- D. typhoid vaccine
Correct answer: A
Rationale: The correct answer is the pneumococcal vaccine. Children with HIV are at increased risk of pneumococcal infections, so the pneumococcal vaccine is recommended as a supplemental vaccine for them. The hepatitis A vaccine is not routinely given to HIV-positive children unless they have other risk factors for hepatitis A. Lyme disease vaccine is for individuals at risk for Lyme disease, not routinely recommended for a 2-year-old. Typhoid vaccine is typically given to individuals traveling to endemic areas or working in settings with potential exposure to Salmonella typhi, not a routine vaccine for a 2-year-old with HIV.
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