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Questions 227

NCLEX-PN

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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 1 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:


Question 2 of 5

The nurse is discussing hemophilia with a group of parents. Which child is most likely to have classic hemophilia?

Correct Answer: A

Rationale: Classic hemophilia (
A) is X-linked recessive; males whose mothers are carriers have a 50% chance of inheriting it, as males inherit the X chromosome from their mother.

Question 3 of 5

The nurse is caring for a client who had a cholecystectomy 24 hours ago. The client reports nausea and has not had a bowel movement since surgery. The nurse should

Correct Answer: A

Rationale: Nausea post-cholecystectomy may be due to anesthesia or pain medication, and an ordered antiemetic addresses this symptom promptly. Ambulation (
B) and high-fiber diet (
C) promote bowel movement but don’t address nausea, and notification (
D) is unnecessary unless symptoms persist or worsen.

Extract:

The nurse would expect an elderly client with a hearing loss caused by aging to have:


Question 4 of 5

The nurse would expect an elderly client with a hearing loss caused by aging to have:

Correct Answer: D

Rationale: Presbycusis, age-related hearing loss, results from inner ear damage.

Extract:


Question 5 of 5

A 15 year-old client with a lengthy confining illness is most at risk for altered psycho-emotional growth and development due to

Correct Answer: C

Rationale: Dependence. The client role fosters dependency, which adolescents may react to with rejection or withdrawal.

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