NCLEX-PN Test #14 1

Question 1

A nurse is caring for a patient receiving continuous enteral tube feedings. The patient is found to have a gastric residual volume of 350 mL. What is the priority action?

Accepted Answer

Hold the feeding, recheck residual in 1 hour, and notify the provider

Answer

Continue the feeding at the current rate

Answer

Increase the feeding rate to compensate for delayed absorption

Answer

Flush the tube with 30 mL of water and resume feeding

Question 2

A nurse is teaching a patient with iron-deficiency anemia about dietary choices. Which statement by the patient indicates a need for further teaching?

Accepted Answer

'I should take my iron supplement with milk to reduce stomach upset.'

Answer

'I should eat more red meat, beans, and dark leafy greens.'

Answer

'Drinking orange juice with my iron supplement will help my body absorb it.'

Answer

'I will cook with cast iron pans to add some iron to my food.'

Question 3

A nurse is caring for a patient on a potassium-restricted diet who has chronic kidney disease. Which food choice indicates the patient understands the dietary restrictions?

Accepted Answer

White rice with green beans

Answer

Baked potato with skin

Answer

Banana and orange juice

Answer

Tomato soup with whole grain crackers

Question 4

A patient with dysphagia is at high risk for aspiration. Which nursing intervention is most important during meals?

Accepted Answer

Position the patient in high Fowler's and keep them upright for at least 30–45 minutes after eating

Answer

Serve only liquids to make swallowing easier

Answer

Feed the patient quickly to minimize fatigue

Answer

Tilt the patient's head backward to open the airway during swallowing

Question 5

A nurse is preparing to administer a tube feeding and checks tube placement. Which is the most reliable method to confirm nasogastric tube placement in a clinical setting?

Accepted Answer

Check the pH of aspirated fluid (pH 5 or less indicates gastric placement)

Answer

Auscultate over the epigastrium while injecting air

Answer

Observe for bubbling when the end of the tube is placed in water

Answer

Note the tube length markings at the nose

Question 6

A postoperative patient who had bowel surgery is asking when they can eat. Which assessment finding indicates the patient's GI function has returned?

Accepted Answer

Active bowel sounds are present in all four quadrants

Answer

The patient requests a meal

Answer

The patient reports nausea

Answer

The patient has not had a bowel movement for 24 hours