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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

A corporate executive works 60-80 hours a week. The client is experiencing some physical signs of stress. The nurse teaches the client biofeedback techniques. This is an example of which of the following health-promotion interventions?

Correct Answer: B

Rationale: Biofeedback is a relaxation technique that helps manage stress by teaching control over physiological responses. It is not structure, time management, or exercise. Psychosocial Integrity

Question 3 of 5

A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority?

Correct Answer: A

Rationale: Elevate the leg on 2 pillows. The first goal of nonpharmacologic interventions is to minimize edema of the affected extremity by leg elevation.

Question 4 of 5

The nurse is caring for a client who underwent a total hip replacement 48 hours ago. Which of the following actions is MOST important to prevent complications?

Correct Answer: B

Rationale: Keeping the affected leg in a neutral position (e.g., avoiding adduction or extreme rotation) prevents hip dislocation, a major complication post-hip replacement. Ambulation (
A) is important but secondary, antibiotics (
C) depend on orders, and monitoring infection (
D) is routine.

Question 5 of 5

A nurse is delegating tasks to a nursing assistant. Which of the following tasks is appropriate to delegate?

Correct Answer: C

Rationale: Assisting with ambulation is within a nursing assistant’s scope, promoting safety and mobility. Medication administration, sterile procedures, and care planning require licensed nurse skills.

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