NCLEX PRACTICE EXAM REVISION QUESTIONS AND CORRECT ANSWERS (ALREADY GRADED A+) (2024 UPDATE) 100% GUARANTEED
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Course
NCLEX RN
Institution
NCLEX RN
What is the nurse's primary concern regarding fluid & electrolytes when caring for an elderly pt
who is intermittently confused?
1. risk of dehydration
2. risk of kidney damage
3. risk of stroke
4. risk of bleeding - ANSWER- Answer: 1
Rationale 1: As an adult ages, the thirst mechanism declin...
Rationale 1: The pt with excessive thirst, increased urination & a medical diagnosis of diabetes
insipidus is at risk for Imbalanced Fluid Volume due to the pt &'s excess volume loss that can
increase the serum levels of sodium.
Rationale 2: Excess Fluid Volume is not an issue for pts with diabetes insipidus, especially
during the early stages of treatment.
Rationale 3: Imbalanced Nutrition does not apply.
, Rationale 4: Ineffective Tissue Perfusion does not apply
A pt recovering from surgery has an indwelling urinary catheter. The nurse would contact the pt's
primary healthcare provider with which of the following 24-hour urine output volumes?
1. 600 mL
2. 750 mL
3. 1000 mL
4. 1200 mL - ANSWER- Answer: 1
Rationale 1: A urine output of less than 30 mL per hour must be reported to the primary
healthcare provider. This indicates inadequate renal perfusion, placing the pt at increased risk for
acute renal failure & inadequate tissue perfusion. A minimum of 720 mL over a 24-hour period is
desired (30 mL multiplied by 24 hours equals 720 mL per 24 hours).
A pt is receiving intravenous fluids postoperatively following cardiac surgery. Nursing
assessments should focus on which postoperative complication?
1. fluid volume excess
2. fluid volume deficit
3. seizure activity
4. liver failure - ANSWER- Answer: 1
Rationale 1: Antidiuretic hormone & aldosterone levels are commonly increased following the
stress response before, during, & immediately after surgery. This increase leads to sodium &
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