NCLEX-PN Test #15 1 — Questions and Answers
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?
- Review the patient's fluid intake and output record
- Palpate the suprapubic area for bladder distension (Correct answer)
- Encourage oral fluid intake
- Insert an indwelling urinary catheter immediately
Correct answer: Palpate the suprapubic area for bladder distension
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?
- 'Many people live normal lives with a colostomy. I'll connect you with a support group.' (Correct answer)
- 'You need to focus on your recovery right now. We can discuss your concerns later.'
- 'Your family will help you manage at home — don't worry about going out.'
- 'The ostomy pouch is discreet, so no one will notice it under your clothes.'
Correct answer: 'Many people live normal lives with a colostomy. I'll connect you with a support group.'
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?
- Inflate the balloon immediately — the catheter may be in a spasm
- Withdraw the catheter 1 inch and rotate it
- Remove the catheter and discard; obtain a new sterile catheter for reinsertion
- Advance the catheter another 2–3 inches before assessing for urine (Correct answer)
Correct answer: Advance the catheter another 2–3 inches before assessing for urine
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?
- Administer a Fleet enema as ordered
- Encourage ambulation and increased fluid intake (Correct answer)
- Request a stat abdominal X-ray
- Insert a rectal tube to relieve gas
Correct answer: Encourage ambulation and increased fluid intake
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?
- Polyuria
- Anuria
- Oliguria (Correct answer)
- Normal urinary output
Correct answer: Oliguria
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.
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?
- Hypernatremia
- Hyperkalemia
- Hypokalemia (Correct answer)
- Hypercalcemia
Correct answer: Hypokalemia
Prolonged diarrhea causes significant loss of potassium through the GI tract, leading to hypokalemia. Signs include muscle weakness, fatigue, and cardiac arrhythmias. Monitoring serum potassium and replacing losses is a priority in patients with diarrhea.
NCLEX-PN Test #15 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?