NCLEX-RN
NCLEX RN Exam Prep
1. 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?
- A. From the tip of the nose to the xiphoid process
- B. From the tip of the nose to the earlobe to the xiphoid process
- C. From the earlobe to the xiphoid process
- D. From the tip of the nose to the earlobe to the umbilicus
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.
2. Match the abbreviation with the correct definition:
- A. bid: twice a day
- B. tid: three times a day
- C. ac: before meals
- D. pc: after meals
Correct answer: C
Rationale: The abbreviation 'ac' stands for 'ante cibum,' which means 'before meals.' 'Bid' means twice a day. 'Tid' means three times a day, and 'pc' means after meals. When interpreting medical abbreviations, it is crucial to understand their precise meanings to ensure accurate communication and patient care.
3. A client is diagnosed with ariboflavinosis. Which of the following foods should the nurse serve this client?
- A. Citrus fruits
- B. Milk
- C. Fish
- D. Potatoes
Correct answer: B
Rationale: Ariboflavinosis is a vitamin B-2 deficiency. Symptoms may include cracks around the mouth, inflammation of the tongue, or light sensitivity. Foods rich in vitamin B-2, like milk, liver, green vegetables, or whole grains, are recommended. Citrus fruits (choice A) are good sources of vitamin C, not B-2. Fish (choice C) is a source of protein and omega-3 fatty acids but not a significant source of vitamin B-2. Potatoes (choice D) are a source of carbohydrates but do not provide high levels of vitamin B-2.
4. 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?
- A. Administer the feeding as ordered
- B. Pull the feeding tube out approximately 3 cm
- C. Flush the feeding tube with 60 cc of water
- D. Contact the physician
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.
5. Which of the following is an example of physical abuse?
- A. A slap to the person's hand
- B. Threatening the person
- C. Ignoring and isolating a person
- D. Leaving a patient soiled for hours
Correct answer: A
Rationale: The correct answer is 'A slap to the person's hand.' Slapping, hitting, and punching are clear examples of physical abuse. Physical abuse involves actions that can cause physical harm or injury to a person. Choice B, 'Threatening the person,' falls under the category of emotional or psychological abuse, where threats can cause fear and emotional distress but do not involve physical harm. Choice C, 'Ignoring and isolating a person,' is a form of neglect or emotional abuse, not physical abuse. Choice D, 'Leaving a patient soiled for hours,' is an example of neglect or lack of proper care, which is also not classified as physical abuse.
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