A nurse is caring for a client with a suspected bowel obstruction who

Fundamental of Nursing NCLEX RN Practice Questions

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Question 1 of 5.

A nurse is caring for a client with a suspected bowel obstruction who requires a nasogastric (NG) tube insertion. Place the following actions in the order in which they need to be performed, starting from first to last.

A. Begin inserting the tube. Have the client relax and flex their head toward their chest after the tube has passed through the nasopharynx.
B. Verify tube placement with a radiograph. Check agency policy for specific guidelines.
C. Encourage the client to swallow by taking small sips of water when possible. Then advance the tube as the client swallows.
D. Determine the length of the tube to be inserted. Measure the distance from the tip of the nose to the earlobe to the xiphoid process (NEX) of the sternum.
E. Temporarily anchor the tube to the nose with a small piece of tape.
F. Educate the client on what is going to take place. Instruct client to relax and breathe normally while occluding one naris. Then repeat this action for the other nare. Select the nostril with greater airflow.
G. Advance the tube each time the client swallows until you reach the desired length.

Correct arrangement

F. Educate the client on what is going to take place. Instruct client to relax and breathe normally while occluding one naris. Then repeat this action for the other nare. Select the nostril with greater airflow.
D. Determine the length of the tube to be inserted. Measure the distance from the tip of the nose to the earlobe to the xiphoid process (NEX) of the sternum.
A. Begin inserting the tube. Have the client relax and flex their head toward their chest after the tube has passed through the nasopharynx.
C. Encourage the client to swallow by taking small sips of water when possible. Then advance the tube as the client swallows.
G. Advance the tube each time the client swallows until you reach the desired length.
E. Temporarily anchor the tube to the nose with a small piece of tape.
B. Verify tube placement with a radiograph. Check agency policy for specific guidelines.

Explanation: The correct order is: educate the client (F), measure tube length (D), begin insertion (A), encourage swallowing (C), advance to desired length (G), anchor the tube (E), verify placement with radiograph (B). This sequence ensures safe and effective NGT insertion.

Question 2 of 5.

The nurse recognizes which of the following would contraindicate the use of electronic blood pressure monitoring?

A. Coarse tremors

B. Intrajugular central vascular access device

C. Wearing a wrist watch

D. Cardiac pacemaker

Explanation: Coarse tremors can interfere with accurate electronic blood pressure readings. Intrajugular devices, wrist watches, and pacemakers do not typically contraindicate use.

Question 3 of 5.

The nurse observes a client perform isometric exercises. It would indicate effective understanding if the client

A. Exercises both extremities simultaneously.

B. Knows their heart rate should be monitored while exercising.

C. Practices forced resistance against stable objects.

D. Swings their limbs through the full range of motion.

Explanation: Isometric exercises involve static muscle contraction against resistance, like pushing against a stable object. Simultaneous exercise, heart rate monitoring, and full range of motion are not specific to isometrics.

Question 4 of 5.

The nurse is teaching a client about ambulating with a cane. It would indicate effective teaching if the nurse observes the client

A. Position the cane on their weaker side.

B. Advances their weaker leg first, then the cane.

C. Measures the height of the cane from their wrist crease.

D. Advances the cane 12-16 inches with each step.

Explanation: Advancing the cane 12-16 inches ensures stability. The cane is held on the stronger side, stronger leg moves first, and height is measured to the greater trochanter.

Question 5 of 5.

The nurse is teaching a client about a vegetarian diet. Which of the following foods should the nurse recommend for this diet? Select all that apply.

A. Legumes

B. Almond butter

C. Grilled chicken

D. Apricots

E. Baked fish

F. Seafood salad

Explanation: Vegetarian diets exclude meat, so legumes, almond butter, and apricots are suitable. Chicken, fish, and seafood are not vegetarian.