NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A 47-year-old client has been admitted to the general surgery unit for bowel obstruction. The doctor has ordered that an NG tube be inserted to aid in bowel decompression. When preparing to insert a NG tube, the nurse measures from the:
Correct Answer: D
Rationale: This measurement is ~50 cm (48-49 cm). Fifty centimeters is considered the length necessary for the distal end of the tube to be in place in the stomach. This measurement is too short. This measurement is ~50 cm (47-48 cm). Fifty centimeters is considered the length necessary for the distal end of the tube to be in place in the stomach. This measurement is too short. This measurement gives an approximate indication of the length necessary for the distal end of the tube to be in place in the stomach, but it is not as accurate as actually measuring the client (nose-ear-xiphoid). This is the correct measurement of 50 cm from the tip of the client's nose to the tip of the earlobe to the xiphoid process (called the NEX [nose-ear-xiphoid] measurement). It is approximately equal to the distance necessary for the distal end of the tube to be located in the correct position in the stomach.
Question 2 of 5
A schizophrenic client who is experiencing thoughts of having special powers states that 'I am a messenger from another planet and can rule the earth.' The nurse assesses this behavior as:
Correct Answer: D
Rationale: Clients experiencing ideas of reference believe that information from the environment (e.g., the television) is referring to them. Clients experiencing delusions of persecution believe that others in the environment are plotting against them. Clients experiencing thought broadcasting perceive that others can hear their thoughts. Clients experiencing delusions of grandeur think that they are omnipotent and have superhuman powers.
Question 3 of 5
The nurse is planning dietary changes for a client following an episode of acute pancreatitis. Which diet is suitable for the client?
Correct Answer: B
Rationale: A high-calorie, low-fat diet supports recovery from pancreatitis by reducing pancreatic stimulation while meeting energy needs. High-fat diets exacerbate symptoms, and low-calorie diets are inadequate.
Question 4 of 5
The nurse is performing an assessment on an elderly client who had a total hip repair this morning. Which assessment finding indicates that the patient is in pain?
Correct Answer: D
Rationale: Grimacing during care is a direct behavioral indicator of pain, common in post-operative patients. Elevated blood pressure, inability to concentrate, or dilated pupils may have other causes and are less specific.
Question 5 of 5
At her monthly prenatal visit, a client reports experiencing heartburn. Which nursing measure should be included in her plan of care to help alleviate it?
Correct Answer: C
Rationale: At least eight glasses of fluid per day are encouraged to help dilute stomach contents, thereby decreasing irritation. Alka Seltzer contains aspirin, which is irritating to gastric mucosa, and therefore should be avoided. Small, frequent bland meals help to decrease gastric pressure and to prevent reflux. Lying down after meals may cause gastric reflux and prevents optimal gastric emptying.