NCLEX-RN
NCLEX RN Exam Prep Questions
Question 1 of 5
A nurse is preparing to insert a small-bore nasogastric feeding tube for a client's enteral feedings. In which method does the nurse measure the correct length of the tube?
Correct Answer: B
Rationale: When preparing to insert a nasogastric tube, the nurse must measure the correct length to ensure that the end of the tube will be in the correct position in the stomach. The accurate method to measure the length is from the tip of the nose to the earlobe to the xiphoid process. This length ensures that the end of the tube reaches the stomach, avoiding placement in the small intestine or esophagus.
Choice A is incorrect as it does not include the earlobe, which is essential for accurate measurement.
Choice C is incorrect because measuring from the earlobe alone does not provide the correct length for positioning in the stomach.
Choice D is incorrect as it includes the umbilicus, which is not the appropriate landmark for measuring the length of a nasogastric tube intended for stomach placement.
Question 2 of 5
Your elderly patient has a temperature of 98.5 degrees. Is there anything else that a nurse should do, in addition to documenting this temperature?
Correct Answer: A
Rationale: No, there is nothing else that a nurse should do. A temperature of 98.5 degrees for an elderly patient falls within normal limits. Other choices are incorrect because the temperature is not hyperthermic (abnormally high) or hypothermic (abnormally low), making choices B, C, and D inaccurate responses in this scenario.
Question 3 of 5
A client has fallen asleep in his bed in the hospital. His heart rate is 65 bpm, his muscles are relaxed, and he is difficult to arouse. Which stage of the sleep cycle is this client experiencing?
Correct Answer: C
Rationale: The client in this scenario is experiencing stage 3 of the sleep cycle. In stage 3, the individual has moved into deeper stages of sleep, making it difficult to arouse. Characteristics of stage 3 include relaxed muscles, a decrease in vital signs, and being very still. Stage 3 is a phase of non-REM sleep where the client progresses towards REM sleep and vivid dreams.
Choices A, B, and D are incorrect. Stage 1 is characterized by light sleep, stage 2 is a slightly deeper sleep with sleep spindles and K-complexes, and stage 4 is the deepest stage of sleep with the slowest brain waves.
Question 4 of 5
Which of the following is part of client teaching regarding antiembolism stockings?
Correct Answer: D
Rationale: When educating clients about antiembolism stockings, it is essential to emphasize that the stockings should be smooth from end to end without wrinkles. Wrinkles in the stockings can impede circulation, defeating the purpose of wearing them to prevent blood clot formation. Instructing the client to roll the top portion of the stocking down if it is too long (
Choice
A) is incorrect as it can create unnecessary pressure points. Stockings should be applied with the toes covered at the end (
Choice
B) to ensure proper compression. Measuring for thigh-high stockings should be done from the knee to the foot (
Choice
C) to ensure the correct fit and compression gradient.
Question 5 of 5
A client is being assisted to lie in the Sims' position. In what position does the nurse arrange the client?
Correct Answer: A
Rationale: The Sims' position is a side-lying position used for examinations or comfort. In the Sims' position, the client lies on their side with the upper leg flexed. The abdomen is slightly downward, and the lower arm is positioned behind the body. A pillow can be used to support the leg.
Choice B is incorrect as it describes a position with the client lying on their back with the head lower than the feet.
Choice C is incorrect as it describes a prone position, not the Sims' position.
Choice D is incorrect as it describes a sitting position, not the Sims' position.