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Questions 163

NCLEX-PN

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Question 1 of 5

The nurse prepares equipment for insertion of a large bore nasogastric (NG) tube for a hospitalized client. Which actions should the nurse take to measure and mark the tube? Select all that apply.

Correct Answer: C,D

Rationale:
To measure an NG tube, measure from nose to earlobe to xiphoid process for approximate insertion depth and mark with tape . Folding in half is inaccurate, measuring to stomach is vague, and rubber clamps are not standard.

Question 2 of 5

The nurse is speaking with the parent of a toddler who believes the child has a hearing deficit. Which findings support this suspected diagnosis? Select all that apply.

Correct Answer: A,C,E

Rationale: Signs of hearing deficit in a toddler include withdrawn behavior , monotone speech , and loud speech due to inability to modulate voice. Inintelligible speech at 12 months is normal, and attentiveness suggests intact hearing.

Question 3 of 5

The nurse caring for a client with myasthenia gravis is reviewing the nursing care plan. Which is recognized as the priority nursing diagnosis?

Correct Answer: C

Rationale: Clients with myasthenia gravis have problems with the muscular activity of breathing. Answers A, B, and D are not the priority, so they are wrong.

Question 4 of 5

The nurse observes a nursing assistant caring for an 86-year-old woman who had an open reduction/internal fixation for a fractured femur two days ago. Which action by the nursing assistant needs correction by the nurse?

Correct Answer: B

Rationale: Full weight-bearing two days post-femur fixation is inappropriate, risking hardware failure; partial or non-weight-bearing is typical. Abductor pillows, commodes, and self-bathing are appropriate.

Question 5 of 5

The nurse is collecting data from a client who had a transurethral resection of the prostate 10 hours ago and is receiving continuous bladder irrigation. Which of the following findings would require follow-up?

Correct Answer: D

Rationale: A 200 mL discrepancy between irrigation input and output suggests possible catheter obstruction or absorption, requiring follow-up. Normal vitals , spasm relief , and light pink urine are expected post-TURP.

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