NCLEX-PN Test #14 1 — Questions and Answers
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?
- Continue the feeding at the current rate
- Increase the feeding rate to compensate for delayed absorption
- Hold the feeding, recheck residual in 1 hour, and notify the provider (Correct answer)
- Flush the tube with 30 mL of water and resume feeding
Correct answer: Hold the feeding, recheck residual in 1 hour, and notify the provider
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?
- 'I should eat more red meat, beans, and dark leafy greens.'
- 'Drinking orange juice with my iron supplement will help my body absorb it.'
- 'I should take my iron supplement with milk to reduce stomach upset.' (Correct answer)
- 'I will cook with cast iron pans to add some iron to my food.'
Correct answer: 'I should take my iron supplement with milk to reduce stomach upset.'
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?
- Baked potato with skin
- Banana and orange juice
- White rice with green beans (Correct answer)
- Tomato soup with whole grain crackers
Correct answer: White rice with green beans
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?
- Serve only liquids to make swallowing easier
- Position the patient in high Fowler's and keep them upright for at least 30–45 minutes after eating (Correct answer)
- Feed the patient quickly to minimize fatigue
- Tilt the patient's head backward to open the airway during swallowing
Correct answer: Position the patient in high Fowler's and keep them upright for at least 30–45 minutes after eating
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?
- Auscultate over the epigastrium while injecting air
- Check the pH of aspirated fluid (pH 5 or less indicates gastric placement) (Correct answer)
- Observe for bubbling when the end of the tube is placed in water
- Note the tube length markings at the nose
Correct answer: Check the pH of aspirated fluid (pH 5 or less indicates gastric placement)
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.
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?
- The patient requests a meal
- The patient reports nausea
- Active bowel sounds are present in all four quadrants (Correct answer)
- The patient has not had a bowel movement for 24 hours
Correct answer: Active bowel sounds are present in all four quadrants
Return of active bowel sounds in all four quadrants indicates the return of peristalsis and GI motility after bowel surgery. This is a key assessment finding before initiating oral nutrition. Patient hunger alone does not confirm GI readiness.
NCLEX-PN Test #14 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?