NCLEX RN EXAM 2025 CORRECTLY ANSWERS |
QUESTIONS AND CORRECT DETAILED WITH RATIONALES
ANSWERS
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 situation, the
nurse should clarify the prescription. Options 1, 2, and 4 are appropriate
postoperative interventions.
The nurse is providing discharge instructions to a client following gastrectomy
and should instruct the client to take which measure to assist in preventing
dumping syndrome?
A. Ambulate following a meal.
B. Eat high-carbohydrate foods.
C. Limit the fluids taken with meals.
D. Sit in a high-Fowler's position during meals.
C
Rationale:
Dumping syndrome is a term that refers to a constellation of vasomotor
symptoms that occurs after eating, especially following a gastrojejunostomy
(Billroth II procedure). Early manifestations usually occur within 30 minutes of
eating and include vertigo, tachycardia, syncope, sweating, pallor, palpitations,
and the desire to lie down. The nurse should instruct the client to decrease the
amount of fluid taken at meals and to avoid high-carbohydrate foods, including
fluids such as fruit nectars; to assume a low-Fowler's position during meals; to lie
down for 30 minutes after eating to delay gastric emptying; and to take
antispasmodics as prescribed.
The nurse is reviewing the prescription for a client admitted to the hospital with
a diagnosis of acute pancreatitis. Which interventions would the nurse expect to
be prescribed for the client? Select all that apply.
QUESTIONS AND CORRECT DETAILED WITH RATIONALES
ANSWERS
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 situation, the
nurse should clarify the prescription. Options 1, 2, and 4 are appropriate
postoperative interventions.
The nurse is providing discharge instructions to a client following gastrectomy
and should instruct the client to take which measure to assist in preventing
dumping syndrome?
A. Ambulate following a meal.
B. Eat high-carbohydrate foods.
C. Limit the fluids taken with meals.
D. Sit in a high-Fowler's position during meals.
C
Rationale:
Dumping syndrome is a term that refers to a constellation of vasomotor
symptoms that occurs after eating, especially following a gastrojejunostomy
(Billroth II procedure). Early manifestations usually occur within 30 minutes of
eating and include vertigo, tachycardia, syncope, sweating, pallor, palpitations,
and the desire to lie down. The nurse should instruct the client to decrease the
amount of fluid taken at meals and to avoid high-carbohydrate foods, including
fluids such as fruit nectars; to assume a low-Fowler's position during meals; to lie
down for 30 minutes after eating to delay gastric emptying; and to take
antispasmodics as prescribed.
The nurse is reviewing the prescription for a client admitted to the hospital with
a diagnosis of acute pancreatitis. Which interventions would the nurse expect to
be prescribed for the client? Select all that apply.
