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 flulike 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?
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