NCLEX RN ACTUAL EXAM 2024 TEST BANK 300
QUESTIONS AND CORRECT DETAILED ANSWERS
WITH RATIONALES (VERIFIED ANSWERS) |ALREADY
GRADED A+
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." - answer-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. - answer-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 - answer-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 - answer-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. - answer-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.
A. Maintain NPO (nothing by mouth) status.
B. Encourage coughing and deep breathing.
C. Give small, frequent high-calorie feedings.
D. Maintain the client in a supine and flat position.
E. Give hydromorphone intravenously as prescribed for pain.
F. Maintain intravenous fluids at 10 mL/hr to keep the vein open. - answer-A, B, E
Rationale:
The client with acute pancreatitis normally is placed on NPO status to rest the pancreas and suppress
gastrointestinal secretions, so adequate intravenous hydration is necessary. Because abdominal pain is a
prominent symptom of pancreatitis, pain medications such as morphine or hydromorphone are
prescribed. Meperidine is avoided, as it may cause seizures. Some clients experience lessened pain by
assuming positions that flex the trunk, with the knees drawn up to the chest. A side-lying position with
the head elevated 45 degrees decreases tension on the abdomen and may help ease the pain. The client
is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which
causes the client to take shallow, guarded abdominal breaths. Therefore, measures such as turning,
coughing, and deep breathing are instituted.
The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about
dietary measures to implement during exacerbation episodes. Which statement made by the client
indicates a need for further instruction?
A. "I should increase the fiber in my diet."
B. "I will need to avoid caffeinated beverages."
C. "I'm going to learn some stress reduction techniques."
D. "I can have exacerbations and remissions with Crohn's disease." - answer-A
Rationale:
Crohn's disease is an inflammatory disease that can occur anywhere in the gastrointestinal tract but
most often affects the terminal ileum and leads to thickening and scarring, a narrowed lumen, fistulas,
ulcerations, and abscesses. It is characterized by exacerbations and remissions. If stress increases the
, symptoms of the disease, the client is taught stress management techniques and may require additional
counseling. The client is taught to avoid gastrointestinal stimulants containing caffeine and to follow a
high-calorie and high-protein diet. A low-fiber diet may be prescribed, especially during periods of
exacerbation.
The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is
documentation of the presence of asterixis. How should the nurse assess for its presence?
A. Dorsiflex the client's foot.
B. Measure the abdominal girth.
C. Ask the client to extend the arms.
D. Instruct the client to lean forward. - answer-C
Rationale:
Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are
outstretched, with the palms down, wrists bent up, and fingers spread. Asterixis is the most common
and reliable sign that hepatic encephalopathy is developing. Options 1, 2, and 4 are incorrect.
The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level
is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client?
A. Roast pork
B. Cheese omelet
C. Pasta with sauce
D. Tuna fish sandwich - answer-C
Rationale:
Cirrhosis is a chronic, progressive disease of the liver characterized by diffuse degeneration and
destruction of hepatocytes. The serum ammonia level assesses the ability of the liver to deaminate
protein byproducts. Normal reference interval is 10 to 80 mcg/dL (6 to 47 mcmol/L). Most of the
ammonia in the body is found in the gastrointestinal tract. Protein provided by the diet is transported to
the liver by the portal vein. The liver breaks down protein, which results in the formation of ammonia.
Foods high in protein should be avoided since the client's ammonia level is elevated above the normal
range; therefore, pasta with sauce would be the best selection.
The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine
whether the problem is currently active, the nurse should assess the client for which manifestation of
duodenal ulcer?
QUESTIONS AND CORRECT DETAILED ANSWERS
WITH RATIONALES (VERIFIED ANSWERS) |ALREADY
GRADED A+
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." - answer-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. - answer-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 - answer-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 - answer-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. - answer-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.
A. Maintain NPO (nothing by mouth) status.
B. Encourage coughing and deep breathing.
C. Give small, frequent high-calorie feedings.
D. Maintain the client in a supine and flat position.
E. Give hydromorphone intravenously as prescribed for pain.
F. Maintain intravenous fluids at 10 mL/hr to keep the vein open. - answer-A, B, E
Rationale:
The client with acute pancreatitis normally is placed on NPO status to rest the pancreas and suppress
gastrointestinal secretions, so adequate intravenous hydration is necessary. Because abdominal pain is a
prominent symptom of pancreatitis, pain medications such as morphine or hydromorphone are
prescribed. Meperidine is avoided, as it may cause seizures. Some clients experience lessened pain by
assuming positions that flex the trunk, with the knees drawn up to the chest. A side-lying position with
the head elevated 45 degrees decreases tension on the abdomen and may help ease the pain. The client
is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which
causes the client to take shallow, guarded abdominal breaths. Therefore, measures such as turning,
coughing, and deep breathing are instituted.
The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about
dietary measures to implement during exacerbation episodes. Which statement made by the client
indicates a need for further instruction?
A. "I should increase the fiber in my diet."
B. "I will need to avoid caffeinated beverages."
C. "I'm going to learn some stress reduction techniques."
D. "I can have exacerbations and remissions with Crohn's disease." - answer-A
Rationale:
Crohn's disease is an inflammatory disease that can occur anywhere in the gastrointestinal tract but
most often affects the terminal ileum and leads to thickening and scarring, a narrowed lumen, fistulas,
ulcerations, and abscesses. It is characterized by exacerbations and remissions. If stress increases the
, symptoms of the disease, the client is taught stress management techniques and may require additional
counseling. The client is taught to avoid gastrointestinal stimulants containing caffeine and to follow a
high-calorie and high-protein diet. A low-fiber diet may be prescribed, especially during periods of
exacerbation.
The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is
documentation of the presence of asterixis. How should the nurse assess for its presence?
A. Dorsiflex the client's foot.
B. Measure the abdominal girth.
C. Ask the client to extend the arms.
D. Instruct the client to lean forward. - answer-C
Rationale:
Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are
outstretched, with the palms down, wrists bent up, and fingers spread. Asterixis is the most common
and reliable sign that hepatic encephalopathy is developing. Options 1, 2, and 4 are incorrect.
The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level
is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client?
A. Roast pork
B. Cheese omelet
C. Pasta with sauce
D. Tuna fish sandwich - answer-C
Rationale:
Cirrhosis is a chronic, progressive disease of the liver characterized by diffuse degeneration and
destruction of hepatocytes. The serum ammonia level assesses the ability of the liver to deaminate
protein byproducts. Normal reference interval is 10 to 80 mcg/dL (6 to 47 mcmol/L). Most of the
ammonia in the body is found in the gastrointestinal tract. Protein provided by the diet is transported to
the liver by the portal vein. The liver breaks down protein, which results in the formation of ammonia.
Foods high in protein should be avoided since the client's ammonia level is elevated above the normal
range; therefore, pasta with sauce would be the best selection.
The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine
whether the problem is currently active, the nurse should assess the client for which manifestation of
duodenal ulcer?
