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. The nurse is reviewing the hot/cold theory of health and illness. Which statement best describes the basic tenets of this theory?
- A. The causation of illness is based on supernatural forces that influence the humors of the body.
- B. Herbs and medicines are classified based on their physical characteristics of hot and cold and the humors of the body.
- C. The four humors of the body consist of blood, yellow bile, black bile, and phlegm.
- D. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors of the body.
Correct answer: D
Rationale: The hot/cold theory of health and illness is based on the four humors of the body: blood, phlegm, black bile, and yellow bile. These humors regulate the basic bodily functions, described in terms of temperature, dryness, and moisture. The treatment of disease in this theory involves adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors. Choice A is incorrect as the theory is not based on supernatural forces but on the balance of bodily humors. Choice B is incorrect as herbs and medicines are not classified solely based on their physical characteristics of hot and cold in this theory. Choice C is incorrect as the four humors are blood, phlegm, black bile, and yellow bile, not spiritual connectedness or social aspects. Therefore, the correct choice is D, as it accurately reflects a foundational tenet of the hot/cold theory of health and illness.
3. The healthcare professional is preparing to measure the length, weight, chest, and head circumference of a 6-month-old infant. Which measurement technique is correct?
- A. Measuring the infant's length using a tape measure
- B. Weighing the infant on an electronic standing scale
- C. Measuring the chest circumference at the nipple line with a tape measure
- D. Measuring the head circumference by wrapping the tape measure around the head
Correct answer: C
Rationale: For accurate measurements, specific techniques are required for different parameters in infants. Measuring the chest circumference involves encircling the chest at the nipple line. Length should be measured on a horizontal measuring board. Weight should be measured using a platform-type balance scale. Head circumference measurement entails ensuring the tape is aligned at the eyebrows and prominent frontal and occipital bones for the widest span. Therefore, the correct technique for measuring the chest circumference is at the nipple line with a tape measure. The other options are incorrect because length should be measured on a horizontal board, weight should be measured on a balance scale, and head circumference should be measured around the head, not over the nose and cheekbones.
4. Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when assessing a patient?
- A. Palpation
- B. Inspection
- C. Percussion
- D. Auscultation
Correct answer: A
Rationale: The correct answer is Palpation. Palpation involves using the sense of touch to assess texture, temperature, moisture, and swelling in a patient. This technique allows the nurse to feel for abnormalities and changes in the patient's tissues. Inspection primarily relies on visual assessment, while percussion involves tapping on the body to produce sounds and assess underlying structures. Auscultation, on the other hand, involves listening to sounds within the body using a stethoscope. Therefore, in the context of assessing texture, temperature, moisture, and swelling, palpation is the most appropriate technique.
5. Which of the following is classified as a prerenal condition that affects urinary elimination?
- A. Nephrotoxic medications
- B. Pericardial tamponade
- C. Neurogenic bladder
- D. Polycystic kidney disease
Correct answer: B
Rationale: A prerenal condition is one that causes reduced urinary elimination by affecting the blood flow to the kidneys. Pericardial tamponade is a condition that impacts the heart's ability to pump sufficient blood, leading to decreased blood flow to vital organs such as the kidneys. This reduction in blood flow to the kidneys can result in decreased urine production. The other choices, such as nephrotoxic medications, neurogenic bladder, and polycystic kidney disease, do not primarily affect the blood flow to the kidneys and are not classified as prerenal conditions that impact urinary elimination.
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