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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 42 )

Updated On: 12-Jan-2026
Page 42 of 345
PDF with 862 Questions

A 47-year-old client has been admitted to the general surgery unit for bowel obstruction. The doctor has ordered that an NG tube be inserted to aid in bowel de-compression. When preparing to insert a NG tube, the nurse measures from the:

  1. Lower lip to the shoulder to the upper sternum
  2. Tip of the nose to the lower lip to the umbilicus
  3. End of the tube to the first measurement line on the tube
  4. Tip of the nose to the ear lobe to the xiphoid process or midepigastric area

Answer(s): D

Explanation:

(A) This measurement is _50 cm (48­49 cm). Fifty centimeters is considered the length necessary for the distal end of the tube to be in place in the stomach. This measurement is too short. (B) This measurement is _50 cm (47­48 cm). Fifty centimeters is considered the lengthnecessary for the distal end of the tube to be in place in the stomach. This measurement is too short. (C) This measurement gives an approximate indication of the length necessary for the distal end of the tube to be in place in the stomach, but it is not as accurate as actually measuring the client (nose-earxiphoid). (D) This is the correct measurement of 50 cm from the tip of the client's nose to the tip of the earlobe to the xiphoid process (called the NEX [nose-ear-xiphoid] measurement). It is approximately equal to the distance necessary for the distal end of the tube to be located in the correct position in the stomach.



An 80-year-old widow is living with her son and daughter- in-law. The home health nurse has been making weekly visits to draw blood for a prothrombin time test. The client is taking 5 mg of coumadin per day. She appears more debilitated, and bruises are noted on her face. Elder abuse is suspected. Which of the following are signs of persons who are at risk for abusing an elderly person?

  1. A family member who is having marital problems and is regularly abusing alcohol
  2. A person with adequate communication and coping skills who is employed by the family
  3. A friend of the family who wants to help but is minimally competent
  4. A lifelong friend of the client who is often confused

Answer(s): A

Explanation:

(A) This answer is correct. Two risk factors are identified in this answer. (B) This answer is incorrect. Persons at risk tend to lack communication skills and effective coping patterns. (C) This answer is incorrect. Persons at risk are usually family members or those reluctant to provide care. (D) This answer is incorrect. This individual has a vested interest in providing care.



A 28-year-old client performs a long, involved ritual in getting up and preparing for the day. He became unable to get to his job before noon. His family, in desperation, has admitted him to the hospital's psychiatric unit. On the unit, he is always late for breakfast, which is served at 8 am. The nurse identifies that the best approach to this problem is to:

  1. Allow him to eat late
  2. Suggest that he do the rituals after breakfast
  3. Get him up early so that he can complete the ritual before breakfast
  4. Ask him to get all the other clients up so that he will forget about his ritual

Answer(s): C

Explanation:

(A) Allowing him to eat late is not a solution to the problem because the ritual affects more than just this meal. (B) He is helpless to change this behavior because the rituals occur as a result of an irrational effort to control his anxiety. (C) To interfere with the ritual will increase anxiety. Until the basic problem is resolved, and in turn his need for the ritual relieved, arrange the schedule so that essential activities may be included (such as meals with the group). (D) This approach would be very disruptive to the other clients and would not serve to relieve the anxiety of the client.



The serial sevens test is often used to determine delirium and dementia. This test aids in assessing which of the following?

  1. Abstract thinking
  2. Ability to focus and concentrate thoughts
  3. Judgment
  4. Memory

Answer(s): B

Explanation:

(A) This answer is incorrect. The test measures the abilities to concentrate and calculate. The use of proverbs is the most common way to test abstraction. (B) This answer is correct. The serial sevens test is a common test of calculation ability. It is difficult for the demented or delirious client to perform. (C) This answer is incorrect. The test for judgment should predict whether the individual will behave in a socially accepted manner. (D) This answer is incorrect. In testingmemory, the nurse would attempt to get the client either to recall recent events or to think about past events.



Because a client is taking an MAO inhibitor, it is necessary to discuss the need for adherence to a low-tyramine diet. Which of the following are foods that she should avoid?

  1. Pickled, aged, smoked, and fermented foods
  2. Fresh vegetables
  3. Broiled fresh fish and fowl
  4. Fresh fruit such as apples and oranges

Answer(s): A

Explanation:

(A) These foods may produce elevation in blood pressure when consumed during MAO inhibition therapy. (B) These foods have not been pickled, fermented, smoked, or aged. They contain very little, if any, tyramine or tryptophan. (C) As long as the meat has not been aged or smoked, it is within the dietary regimen. (D) Fresh fruits can be consumed as desired. However, the consumption of bananas is limited.



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