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

The priority is to assess for urinary retention by palpating the suprapubic area for bladder distension. A distended, firm bladder above the pubic symphysis indicates retention. This assessment guides the decision for catheterization or bladder scan before intervening.

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

Acknowledging the patient's feelings, providing accurate information that many people live active normal lives with a colostomy, and offering peer support resources addresses both emotional and educational needs. Dismissing the concern or minimizing the impact is not therapeutic.

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

In female patients the urethra is approximately 3–5 cm (1.5–2 inches) long but the catheter should be advanced 5–7.5 cm (2–3 inches) or until urine flows. If no urine returns, advancing further is appropriate. If the catheter was inadvertently inserted into the vagina, it must be removed and a new sterile catheter used.

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

Conservative non-pharmacologic interventions — increasing ambulation and fluid intake — are the first-line approach for constipation without signs of obstruction. These stimulate peristalsis naturally. Enemas and laxatives are considered after conservative measures fail or as ordered.

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

Oliguria is defined as urine output less than 400 mL in 24 hours (or less than 0.5 mL/kg/hour in adults). An output of 200 mL over 8 hours (25 mL/hr) meets the criteria for oliguria and signals decreased renal perfusion or worsening kidney disease.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #15 1