NCLEX-PN Test #15 1

Question 1

A nurse is caring for a patient 12 hours post-operative following abdominal surgery. The patient has not voided since returning from the OR. What is the priority nursing assessment?

Accepted Answer

Palpate the suprapubic area for bladder distension

Answer

Review the patient's fluid intake and output record

Answer

Encourage oral fluid intake

Answer

Insert an indwelling urinary catheter immediately

Question 2

A nurse is caring for a patient with a new colostomy. The patient states, 'I am so embarrassed — I'll never be able to leave the house.' What is the nurse's best response?

Accepted Answer

'Many people live normal lives with a colostomy. I'll connect you with a support group.'

Answer

'You need to focus on your recovery right now. We can discuss your concerns later.'

Answer

'Your family will help you manage at home — don't worry about going out.'

Answer

'The ostomy pouch is discreet, so no one will notice it under your clothes.'

Question 3

A nurse inserts an indwelling urinary catheter in a female patient. After inserting the catheter approximately 2 inches, no urine returns. What should the nurse do?

Accepted Answer

Advance the catheter another 2–3 inches before assessing for urine

Answer

Inflate the balloon immediately — the catheter may be in a spasm

Answer

Withdraw the catheter 1 inch and rotate it

Answer

Remove the catheter and discard; obtain a new sterile catheter for reinsertion

Question 4

A patient reports not having had a bowel movement in 4 days and complains of abdominal cramping. The nurse's assessment reveals hypoactive bowel sounds. Which intervention should the nurse implement first?

Accepted Answer

Encourage ambulation and increased fluid intake

Answer

Administer a Fleet enema as ordered

Answer

Request a stat abdominal X-ray

Answer

Insert a rectal tube to relieve gas

Question 5

A patient with chronic kidney disease has an output of 200 mL over 8 hours. The nurse understands this finding represents which urinary condition?

Accepted Answer

Oliguria

Answer

Polyuria

Answer

Anuria

Answer

Normal urinary output

Question 6

A nurse is caring for a patient with diarrhea for the past 3 days. Which electrolyte imbalance is the nurse most concerned about?

Accepted Answer

Hypokalemia

Answer

Hypernatremia

Answer

Hyperkalemia

Answer

Hypercalcemia