RN NCLEX EXAM WITH VERIFIED
ANSWERS AND DETAILED RATIONALES
A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this
client? Select all that apply.
A. Administer stool softeners as prescribed.
B. Instruct the client to limit fluid intake to avoid urinary retention. C. Encourage a high-fiber
diet to promote bowel movements without straining.
D. Apply cold packs to the anal-rectal area over the dressing until the packing is removed.
E. Help the client to a Fowler's position to place pressure on the rectal area and decrease
bleeding. ✔️✔️A, C, D
Rationale:
Nursing interventions after a hemorrhoidectomy are aimed at management of pain and avoidance
of bleeding and incision rupture. Stool softeners and a high-fiber diet will help the client avoid
straining, thereby reducing the chances of rupturing the incision. An ice pack will increase
comfort and decrease bleeding. Options 2 and 5 are incorrect interventions.
The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about
substances to avoid. Which items should the nurse include on this list? Select all that apply.
A. Coffee
,B. Chocolate
C. Peppermint
D. Nonfat milk
E. Fried chicken
F. Scrambled eggs ✔️✔️A, B, C, E
Rationale:
Foods that decrease lower esophageal sphincter (LES) pressure and irritate the esophagus will
increase reflux and exacerbate the symptoms of GERD and therefore should be avoided.
Aggravating substances include coffee, chocolate, peppermint, fried or fatty foods, carbonated
beverages, and alcohol. Options 4 and 6 do not promote this effect.
The primary health care provider has determined that a client has contracted hepatitis A based on
flu-like symptoms and jaundice. Which statement made by the client supports this medical
diagnosis?
A. "I have had unprotected sex with multiple partners."
B. "I ate shellfish about 2 weeks ago at a local restaurant."
C. "I was an intravenous drug abuser in the past and shared needles."
D. "I had a blood transfusion 30 years ago after major abdominal surgery." ✔️✔️B
Rationale:
,Hepatitis A is transmitted by the fecal-oral route via contaminated water or food (improperly
cooked shellfish), or infected food handlers. Hepatitis B, C, and D are transmitted most
commonly via infected blood or body fluids, such as in the cases of intravenous drug abuse,
history of blood transfusion, or unprotected sex with multiple partners.
The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-
tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention
is most appropriate?
A. Clamp the T-tube.
B. Irrigate the T-tube.
C. Document the findings.
D. Notify the primary health care provider. ✔️✔️C
Rationale:
Following cholecystectomy, drainage from the T-tube is initially bloody and then turns a
greenish-brown color. The drainage is measured as output. The amount of expected drainage will
range from 500 to 1000 mL/day. The nurse would document the output.
The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding
would most likely indicate perforation of the ulcer?
A. Bradycardia
, B. Numbness in the legs
C. Nausea and vomiting
D. A rigid, board-like abdomen ✔️✔️D
Rationale:
Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable
severe pain beginning in the midepigastric area and spreading over the abdomen, which becomes
rigid and boardlike. Nausea and vomiting may occur. Tachycardia may occur as hypovolemic
shock develops. Numbness in the legs is not an associated finding.
The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure). Which
postoperative prescription should the nurse question and verify?
A. Leg exercises
B. Early ambulation
C. Irrigating the nasogastric tube
D. Coughing and deep-breathing exercises ✔️✔️C
Rationale:
In a gastrojejunostomy (Billroth II procedure), the proximal remnant of the stomach is
anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing
the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube
after gastric surgery, unless specifically prescribed by the primary health care provider. In this
ANSWERS AND DETAILED RATIONALES
A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this
client? Select all that apply.
A. Administer stool softeners as prescribed.
B. Instruct the client to limit fluid intake to avoid urinary retention. C. Encourage a high-fiber
diet to promote bowel movements without straining.
D. Apply cold packs to the anal-rectal area over the dressing until the packing is removed.
E. Help the client to a Fowler's position to place pressure on the rectal area and decrease
bleeding. ✔️✔️A, C, D
Rationale:
Nursing interventions after a hemorrhoidectomy are aimed at management of pain and avoidance
of bleeding and incision rupture. Stool softeners and a high-fiber diet will help the client avoid
straining, thereby reducing the chances of rupturing the incision. An ice pack will increase
comfort and decrease bleeding. Options 2 and 5 are incorrect interventions.
The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about
substances to avoid. Which items should the nurse include on this list? Select all that apply.
A. Coffee
,B. Chocolate
C. Peppermint
D. Nonfat milk
E. Fried chicken
F. Scrambled eggs ✔️✔️A, B, C, E
Rationale:
Foods that decrease lower esophageal sphincter (LES) pressure and irritate the esophagus will
increase reflux and exacerbate the symptoms of GERD and therefore should be avoided.
Aggravating substances include coffee, chocolate, peppermint, fried or fatty foods, carbonated
beverages, and alcohol. Options 4 and 6 do not promote this effect.
The primary health care provider has determined that a client has contracted hepatitis A based on
flu-like symptoms and jaundice. Which statement made by the client supports this medical
diagnosis?
A. "I have had unprotected sex with multiple partners."
B. "I ate shellfish about 2 weeks ago at a local restaurant."
C. "I was an intravenous drug abuser in the past and shared needles."
D. "I had a blood transfusion 30 years ago after major abdominal surgery." ✔️✔️B
Rationale:
,Hepatitis A is transmitted by the fecal-oral route via contaminated water or food (improperly
cooked shellfish), or infected food handlers. Hepatitis B, C, and D are transmitted most
commonly via infected blood or body fluids, such as in the cases of intravenous drug abuse,
history of blood transfusion, or unprotected sex with multiple partners.
The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-
tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention
is most appropriate?
A. Clamp the T-tube.
B. Irrigate the T-tube.
C. Document the findings.
D. Notify the primary health care provider. ✔️✔️C
Rationale:
Following cholecystectomy, drainage from the T-tube is initially bloody and then turns a
greenish-brown color. The drainage is measured as output. The amount of expected drainage will
range from 500 to 1000 mL/day. The nurse would document the output.
The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding
would most likely indicate perforation of the ulcer?
A. Bradycardia
, B. Numbness in the legs
C. Nausea and vomiting
D. A rigid, board-like abdomen ✔️✔️D
Rationale:
Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable
severe pain beginning in the midepigastric area and spreading over the abdomen, which becomes
rigid and boardlike. Nausea and vomiting may occur. Tachycardia may occur as hypovolemic
shock develops. Numbness in the legs is not an associated finding.
The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure). Which
postoperative prescription should the nurse question and verify?
A. Leg exercises
B. Early ambulation
C. Irrigating the nasogastric tube
D. Coughing and deep-breathing exercises ✔️✔️C
Rationale:
In a gastrojejunostomy (Billroth II procedure), the proximal remnant of the stomach is
anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing
the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube
after gastric surgery, unless specifically prescribed by the primary health care provider. In this
