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Questions 227

NCLEX-PN

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Extract:


Question 1 of 5

During a routine examination, the nurse notes that the client seems unusually anxious. Anxiety can affect the genitourinary system by:

Correct Answer: D

Rationale: Anxiety may stimulate or hinder micturition. Its most noticeable effect is to cause frequent voiding and urinary urgency. However, when anxiety leads to generalized muscle tension, it may hinder urination because the perineal muscles must relax to complete micturition. Anxiety doesn't slow the glomerular filtration rate, increase sodium resorption, or decrease potassium excretion.

Extract:

The patient has been receiving 2500 ml of IV fluid and 300 to 400 ml of oral intake daily for 2 days. The patient's urine output has been decreasing and now has been less than 40 ml per hour for the past 3 hours.


Question 2 of 5

The nurse should immediately:

Correct Answer: B

Rationale: Low urine output suggests renal or fluid issues, requiring vital signs and breath sound assessment.

Extract:

After a craniotomy for the removal of hematoma sustained in a fall, the patient is returned to the recovery room.


Question 3 of 5

The nurse places the child in a semi-fowler's position to

Correct Answer: A

Rationale: This position utilizes gravity to drain fluid from the head and prevent fluid accumulation, reducing the risk of increased intracranial pressure.

Extract:

While retrieving her voice messages, the public health nurse received a call from the patient who is receiving short acting insulin for her diabetes. The patient states, 'I know I have a severely low sugar since the regular insulin was given 3 hours ago and it peaks in 2 hours.'


Question 4 of 5

When the nurse returns the call, the first question she will ask the patient would be?

Correct Answer: B

Rationale: Hypoglycemia is likely if the patient has not eaten post-insulin, making this the priority question to assess the cause.

Extract:


Question 5 of 5

A 3 year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, skin hot to touch, sits leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first?

Correct Answer: D

Rationale: These findings suggest a medical emergency and may be due to epiglottitis. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate attention in a facility equipped to perform intubation or a tracheostomy in the event of further or complete obstruction.

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