NCLEX-RN
NCLEX RN Exam Prep Questions
Extract:
Question 1 of 5
A healthcare professional is preparing to administer an enteral feeding through a gastrostomy tube. Before administering the feeding, the healthcare professional aspirates some stomach contents and checks the pH. The result is 3.9. What is the next action of the healthcare professional?
Correct Answer: A
Rationale: When the pH of the aspirated stomach contents is 4 or less, it indicates that the gastrostomy tube is in the stomach, confirming correct placement. A pH of 3.9 falls within this range, so the healthcare professional can proceed with administering the enteral feeding. There is no need to adjust the tube placement, flush with water, or contact the physician in this situation as the tube is appropriately positioned for feeding.
Question 2 of 5
While caring for Mr. Charles Y., you see a notation on the nursing care plan that states, 'remind the patient to use the incentive spirometer tid.' This patient will be reminded at which of the following times?
Correct Answer: C
Rationale: The abbreviation 'tid' stands for 'ter in die,' which means three times a day. In this case, the patient should be reminded to use the incentive spirometer at 10 am, 2 pm, and 6 pm. Option A, '10 am,' is too infrequent for tid dosing. Option B, '10 am and 2 pm,' is missing the third reminder at 6 pm. Option D, '10 am, 2 pm, 6 pm, and 10 pm,' includes an additional time that is not part of the standard tid dosing schedule.
Question 3 of 5
A client is complaining of pain that starts in the shoulder and travels down the length of his arm. This type of pain is referred to as:
Correct Answer: C
Rationale: Radiating pain is the correct term for pain that originates in one part of the body and extends to other related areas. In this scenario, the pain starting in the shoulder and traveling down the arm describes radiating pain. Referred pain (
Choice
A) is pain felt at a site different from the actual origin of the pain. Superficial pain (
Choice
B) is pain that arises from the skin or tissues just beneath it. Precipitating pain (
Choice
D) refers to pain that is triggered by specific actions or events, not the characteristic described in the question.
Question 4 of 5
When cleansing the genital area during perineal care, the nurse should _____________.
Correct Answer: B
Rationale: During perineal care, when cleansing the genital area of an uncircumcised male patient, it is crucial to retract the foreskin to clean the area underneath. This helps in the removal of smegma, a substance that can accumulate and lead to bacterial growth and infection if not cleaned properly. The foreskin should then be replaced back to its original position after cleaning to ensure proper hygiene and prevent any potential complications.
Choices A, C, and D are incorrect because they do not address the specific care required for an uncircumcised penis, which involves retracting and replacing the foreskin.
Question 5 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.