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Questions 227

NCLEX-PN

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Extract:


Question 1 of 5

The nurse is caring for a client with a colostomy. The client reports that the colostomy bag is leaking. The nurse should

Correct Answer: C

Rationale: A leaking colostomy bag may indicate poor fit, skin irritation, or stoma changes, so assessing the stoma and peristomal skin is the first step to determine the cause and plan interventions. Taping (
A) is temporary, emptying/reapplying (
B) may not address the issue, and physician notification (
D) is premature.

Extract:

Forty eight to 72 hours post birth, blood test for PKU is taken on the neonate.


Question 2 of 5

This test is called

Correct Answer: B

Rationale: The Guthrie blood test reliably detects abnormal phenylalanine levels as early as 4 days of age, provided the infant is fed a milk diet.

Extract:


Question 3 of 5

Observation should be ordered for the client using hallucinogens because, hallucinogens

Correct Answer: B

Rationale: Hallucinogens cause altered perception, posing risks of harm due to impaired judgment, necessitating close observation. They do not typically cause respiratory depression or rapid dependence.

Extract:

Which of the following female patients is at the highest risk for the development of breast cancer?


Question 4 of 5

A 28-year-old who was 10 years old at menarche.

Correct Answer: A

Rationale: Early menarche (before age 12) is a known risk factor for breast cancer due to prolonged exposure to estrogen.

Extract:


Question 5 of 5

A pregnant Asian client who is experiencing morning sickness wants to take ginger to relieve the nausea. Which of the following responses by the nurse is appropriate?

Correct Answer: A

Rationale: Ginger is a recognized remedy for nausea, and consulting the physician respects the client's cultural preferences while ensuring safety. The other responses are dismissive or culturally insensitive. Physiological Adaptation

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