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 client with Hodgkin's lymphoma is receiving Platinol (cisplatin). To help prevent nephrotoxicity, the nurse should:
Correct Answer: B
Rationale: Cisplatin is nephrotoxic, and adequate hydration helps dilute the drug and protect the kidneys, reducing the risk of renal damage.
Question 3 of 5
The nurse is caring for a client with a history of diverticulitis. Which meal selection is best suited for the client?
Correct Answer: A
Rationale: Diverticulitis requires a low-fiber diet during acute phases. Broiled fish, steamed carrots, and gelatin are low-fiber and suitable. The other options contain high-fiber or irritating foods.
Question 4 of 5
A 4-year-old boy is brought to the emergency room with bruises on his head, face, arms, and legs. His mother states that he fell down some steps. The nurse suspects that he may have been physically abused. In accordance with the law, the nurse must:
Correct Answer: B
Rationale: Although the nurse probably would talk to the physician about these concerns, the nurse is not required by law to do so. All healthcare workers are required by the Federal Child Abuse Prevention and Treatment Act of 1974 to report suspected and actual cases of child abuse and/or neglect. Talking to the child's father may or may not help the child, and the nurse is not required by law to do so. Confrontation may not be indicated; the nurse is not required by law to confront the child's mother with these suspicions.
Question 5 of 5
When assessing fetal heart rate status during labor, the monitor displays late decelerations with tachycardia and decreasing variability. What action should the nurse take?
Correct Answer: D
Rationale: This is not a normal occurrence. Late decelerations need prompt intervention for immediate infant recovery.
To increase O2 perfusion to the unborn infant, the mother should be placed on her left side. IV fluids should be increased, not decreased. Immediate action is warranted, such as reporting findings, turning mother on left side, administering O2, discontinuing oxytocin (Pitocin), assessing maternal blood pressure and the labor process, preparing for immediate cesarean delivery, and explaining plan of action to client.