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

A gastric residual volume greater than 250–500 mL (facility protocols vary) suggests delayed gastric emptying. The nurse should hold the feeding to reduce aspiration risk, re-check residuals in 1 hour, and notify the provider for further orders such as a prokinetic agent.

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

Calcium in milk binds to iron and significantly reduces its absorption. Iron supplements should be taken on an empty stomach with water or vitamin C (ascorbic acid), which enhances absorption. Milk, antacids, and calcium supplements should be avoided within 2 hours of an iron dose.

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

White rice and green beans are relatively low in potassium — appropriate for a potassium-restricted diet. Baked potatoes (especially with skin), bananas, orange juice, and tomatoes are high in potassium and should be limited or avoided in chronic kidney disease.

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

For patients with dysphagia, positioning in high Fowler's (90 degrees) uses gravity to assist with swallowing and reduces aspiration risk. Keeping the patient upright for 30–45 minutes post-meal further prevents reflux and aspiration. Tilting the head back is dangerous as it can open the airway and allow food to enter the trachea.

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

Checking the pH of aspirated gastric contents is a reliable bedside method — gastric pH is typically 5 or less. Auscultation (the 'whoosh' test) is unreliable and no longer recommended as a sole confirmation method. X-ray remains the gold standard, especially for newly placed tubes.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #14 1