Practice NCLEX RN Test
Question 1 of 5.
A new graduate nurse is assigned to a 30-year-old female requiring NG tube feeding. The preceptor reminds the graduate nurse to check placement of the NG tube before administering the feeding. The best way to do this is by
A. verifying placement with an X-ray before each feeding.
B. aspirating gastric contents and testing the contents on a pH paper.
C. auscultating bowel sounds after administering a 30 cc air bolus.
D. auscultating bowel sounds after administering the first 10 cc of tube feeding.
Explanation: Aspirating gastric contents and checking pH (≤5.5 indicates gastric placement) is the most reliable bedside method to confirm NG tube placement.
Question 2 of 5.
A mother brings her two-year-old boy to the pediatrician’s office. Which of the following symptoms would suggest to the nurse that the child has strabismus?
A. When the child draws, he places his head close to the table.
B. The child rubs his eyes frequently.
C. The child closes one eye to see a poster on the wall.
D. The child is unable to see objects in the periphery of his visual field.
Explanation: visual axes are not parallel so the brain receives two images
Question 3 of 5.
A nurse is caring for a 37-year-old woman with metastatic ovarian cancer admitted for nausea and vomiting. The physician orders total parenteral nutrition (TPN), a nutritional consult, and diet recall. Which of the following is the BEST indication that the patient’s nutritional status has improved after 4 days?
A. The patient eats most of the food served to her.
B. The patient has gained 1 pound since admission.
C. The patient’s albumin level is 4.0 mg/dL.
D. The patient’s hemoglobin is 8.5 g/dL.
Explanation: albumin levels are best indicators of long-term nutritional status
Question 4 of 5.
A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse. The physician orders include: 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the man performing a blood sugar analysis. The result is 50 mg/dL. The nurse would expect the client to be
A. confused with cold, clammy skin and a pulse of 110.
B. lethargic with hot, dry skin and rapid, deep respirations.
C. alert and cooperative with a BP of 130/80 and respirations of 12.
D. short of breath, with distended neck veins and a bounding pulse of 96.
Explanation: symptoms of hypoglycemia, normal blood sugar 70-110 mg/dL
Question 5 of 5.
Which of the following is a correctly stated nursing diagnosis for a client with abruptio placentae?
A. Infection related to obstetrical trauma.
B. Potential for fetal injury related to abruptio placentae.
C. Potential alteration in tissue perfusion related to depletion of fibrinogen.
D. Fluid volume deficit related to bleeding.
Explanation: abruptio placenta is premature separation of a normally implanted placenta leading to hemorrhage; fluid volume deficit is a major nursing concern with these clients