Kaplan NCLEX Readiness Exam
Kaplan NCLEX Readiness Exam Practice Questions, Answers
Study online at https://quizlet.com/_hlke1x
1. The nurse cares for a client with 1) CORRECT - Implementation: outcome desired; cuff
a cuffed tracheostomy tube. Be- inflation decreases the risk of aspiration; cuff position
fore performing oral care, the nurse and pressure should be assessed frequently; swal-
notes that the client's tracheostomy lowing and breathing will cause tracheostomy tube
cuff is inflated. Which of the follow- movement
ing is the MOST appropriate action
for the nurse to take? 2) Implementation: outcome not desired; accumulat-
ed oral secretions above the cuff will drain into the
1. Leave the cuff inflated and suc- bronchi; increased risk of infection
tion through the tracheostomy.
2. Deflate the cuff and suction 3) Implementation: outcome not desired; cuff pres-
through the tracheostomy tube. sure should be less than 20 mm Hg (25 cm H2O); risk
3. Inflate the cuff pressure to 40 of trauma to trachea with higher pressures
mm Hg before suctioning.
4) Implementation: outcome not desired; increases
4. Adjust the wall suction pressure
the risk of trauma to lower airways
to 160 to 180 mm Hg before suc-
tioning.
2. A young adult brings a friend to the 1) Assessment: outcome not priority but may be ap-
emergency department and states propriate; pinpoint pupils are a sign of heroin over-
that the friend has been using hero- dose
in. Which action by the nurse is the
MOST appropriate? 2) CORRECT - Assessment: outcome priority; shallow
respirations seen; impaired alveolar gas exchange
1. Assess pupil size and reactivity. and possible respiratory arrest
2. Assess oxygen saturation levels.
3. Palpate dorsalis pedis pulses. 3) Assessment: outcome not priority; most important
4. Ask the client if he knows today's to assess airway and breathing
date.
4) Assessment: outcome not priority but may be ap-
propriate; drowsiness and euphoria may be seen; not
priority
Page 1
, Kaplan NCLEX Readiness Exam
Kaplan NCLEX Readiness Exam Practice Questions, Answers
Study online at https://quizlet.com/_hlke1x
3. The client tells the clinic nurse that 1) Assessment: outcome not priority but may be ap-
the client is thinking about us- propriate; can be asked as part of assessment
ing nicotine polacrilex (Nicorette).
Which question is MOST important 2) Assessment: outcome not priority but may be ap-
for the nurse to ask? propriate; should be assessed for further teaching
1. "Have you tried other methods 3) CORRECT - Assessment: outcome priority; action
to stop smoking?" of nicotine is vasoconstriction; increases heart rate
2. "How long have you been smok- and myocardial oxygen consumption; increased risk
ing?" of angina and myocardial infarction
3. "Have you ever had chest pain?"
4) Assessment: outcome may be appropriate but not
4. "Do you have a partial dental
priority; gum is place between cheek and gums; may
bridge?"
stain dental work
4. The nurse cares for the client with 1) Assessment: outcome not priority but may be ap-
a client controlled analgesia (PCA) propriate; if tubing is obstructed, alarm is activated
pump. The nurse determines that
the client has pressed the button 11 2) Assessment: outcome may be appropriate but not
times and received 6 doses of mor- priority; more important to determine pain level, de-
phine during the last hour. Which scription of the pain, region and radiation of the pain,
is the MOST appropriate action for and relieving factors
the nurse to take?
3) Implementation: outcome not desired; more im-
1. Assess the patency of the PCA IV portant to assess severity of pain and pain relief first
tubing.
4) CORRECT - Assessment: outcome priority; must val-
2. Determine the client's under-
idate that client is in pain before implementation
standing of the PCA pump func-
tion.
3. Obtain an order to begin a PCA
infusion of fentanyl.
4. Ask the client to describe the
pain.
Page 2
, Kaplan NCLEX Readiness Exam
Kaplan NCLEX Readiness Exam Practice Questions, Answers
Study online at https://quizlet.com/_hlke1x
5. A pregnant woman receives an 1) Implementation: outcome not desired; no increase
epidural anesthetic. After adminis- in venous return
tration of the epidural anesthetic,
the client's blood pressure changes 2) Implementation: outcome not desired; will de-
from 120/84 to 94/50. Which action crease venous return
by the nurse is MOST appropriate?
3) CORRECT - Implementation: outcome desired; will
1. Place the client flat on her back. increase venous return and cardiac output; fetal pres-
2. Elevate the head of the bed 30 sure on inferior vena cava reduced
degrees.
4) Implementation: outcome not desired; elevation of
3. Place the client on her left side
legs will increase venous return, but fetal pressure on
with her legs flexed.
vena cava will prevent blood return to heart
4. Place the client supine with the
foot of the bed elevated.
6. A nursing order, "Increase fluid in- 1) CORRECT - Assessment: outcome priority; increased
take" is written for a client di- amounts of antidiuretic hormone secreted; urine out-
agnosed with dehydration. Which put decreased and concentrated
finding BEST indicates improving
fluid status? 2) Assessment: outcome not priority; indicates that
blood is hemoconcentrated
1. Urinary output of 1,500 mL in 24
hours. 3) Assessment: outcome not priority; normal intake is
2. Serum hematocrit 52%. 1,500 mL in 24 hours
3. Oral fluid intake of 900 mL in 24
4) Assessment: outcome not priority; normal BP is
hours.
120/80
4. Blood pressure of 100/82.
7. The nurse prepares to administer 1) Implementation: outcome not a problem; no inter-
the initial dose of oral enalapril (Va- action with ACE inhibitors; is an SSRI antidepressant
sotec) 20 mg in the morning. Which
medication should the nurse ques- 2) CORRECT - Implementation: outcome potential
Page 3
, Kaplan NCLEX Readiness Exam
Kaplan NCLEX Readiness Exam Practice Questions, Answers
Study online at https://quizlet.com/_hlke1x
tion giving to the client? problem; may promote significant diuresis; first dose
of ACE inhibitors increases risk of "first dose" phe-
1. 20 mg oral escitalopram (Celexa) nomenon due to vasodilation; combination of vasodi-
in the morning. lation and diuresis increases risk of orthostatic hy-
2. 40 mg oral furosemide (Lasix) in potension
the morning.
3. 300 mg of oral gabapentin (Neu- 3) Implementation: outcome not a problem; no inter-
rontin) twice daily. action; gabapentin classified as antiseizure medica-
4. 10 mg zolpidem (Ambien) at bed- tion; off-label use for neuropathic pain
time.
4) Implementation: outcome not a problem; is a hyp-
notic; no interaction with ACE inhibitors
8. The home care nurse visits a client 1) Assessment: outcome desired; risk of infection at
with a halo fixator traction device. pin sites; client should be taught signs of inflamma-
Which client statement MOST con- tion and infection
cerns the nurse?
2) Implementation: outcome desired; showers in-
crease risk of infection at pin sites
1. "My wife looks at the pin sites 3) CORRECT - Implementation: outcome not desired
every day." and may be a problem; client is not able to turn with
2. "I like to bathe in the tub." halo device; increases the risk of injury to self and
3. "I drove to the library yesterday." others
4. "I drink with a straw."
4) Implementation: outcome desired; difficulty ma-
nipulating cup or glass due to immobilized neck
9. The nurse cares for a client di- 1) CORRECT - Assessment: outcome desired; clients
agnosed with depression. Which with depression may have increased or decreased
statement by the client indicates sleep time
improvement?
2) Assessment: outcome not desired; lack of appetite
Page 4
Kaplan NCLEX Readiness Exam Practice Questions, Answers
Study online at https://quizlet.com/_hlke1x
1. The nurse cares for a client with 1) CORRECT - Implementation: outcome desired; cuff
a cuffed tracheostomy tube. Be- inflation decreases the risk of aspiration; cuff position
fore performing oral care, the nurse and pressure should be assessed frequently; swal-
notes that the client's tracheostomy lowing and breathing will cause tracheostomy tube
cuff is inflated. Which of the follow- movement
ing is the MOST appropriate action
for the nurse to take? 2) Implementation: outcome not desired; accumulat-
ed oral secretions above the cuff will drain into the
1. Leave the cuff inflated and suc- bronchi; increased risk of infection
tion through the tracheostomy.
2. Deflate the cuff and suction 3) Implementation: outcome not desired; cuff pres-
through the tracheostomy tube. sure should be less than 20 mm Hg (25 cm H2O); risk
3. Inflate the cuff pressure to 40 of trauma to trachea with higher pressures
mm Hg before suctioning.
4) Implementation: outcome not desired; increases
4. Adjust the wall suction pressure
the risk of trauma to lower airways
to 160 to 180 mm Hg before suc-
tioning.
2. A young adult brings a friend to the 1) Assessment: outcome not priority but may be ap-
emergency department and states propriate; pinpoint pupils are a sign of heroin over-
that the friend has been using hero- dose
in. Which action by the nurse is the
MOST appropriate? 2) CORRECT - Assessment: outcome priority; shallow
respirations seen; impaired alveolar gas exchange
1. Assess pupil size and reactivity. and possible respiratory arrest
2. Assess oxygen saturation levels.
3. Palpate dorsalis pedis pulses. 3) Assessment: outcome not priority; most important
4. Ask the client if he knows today's to assess airway and breathing
date.
4) Assessment: outcome not priority but may be ap-
propriate; drowsiness and euphoria may be seen; not
priority
Page 1
, Kaplan NCLEX Readiness Exam
Kaplan NCLEX Readiness Exam Practice Questions, Answers
Study online at https://quizlet.com/_hlke1x
3. The client tells the clinic nurse that 1) Assessment: outcome not priority but may be ap-
the client is thinking about us- propriate; can be asked as part of assessment
ing nicotine polacrilex (Nicorette).
Which question is MOST important 2) Assessment: outcome not priority but may be ap-
for the nurse to ask? propriate; should be assessed for further teaching
1. "Have you tried other methods 3) CORRECT - Assessment: outcome priority; action
to stop smoking?" of nicotine is vasoconstriction; increases heart rate
2. "How long have you been smok- and myocardial oxygen consumption; increased risk
ing?" of angina and myocardial infarction
3. "Have you ever had chest pain?"
4) Assessment: outcome may be appropriate but not
4. "Do you have a partial dental
priority; gum is place between cheek and gums; may
bridge?"
stain dental work
4. The nurse cares for the client with 1) Assessment: outcome not priority but may be ap-
a client controlled analgesia (PCA) propriate; if tubing is obstructed, alarm is activated
pump. The nurse determines that
the client has pressed the button 11 2) Assessment: outcome may be appropriate but not
times and received 6 doses of mor- priority; more important to determine pain level, de-
phine during the last hour. Which scription of the pain, region and radiation of the pain,
is the MOST appropriate action for and relieving factors
the nurse to take?
3) Implementation: outcome not desired; more im-
1. Assess the patency of the PCA IV portant to assess severity of pain and pain relief first
tubing.
4) CORRECT - Assessment: outcome priority; must val-
2. Determine the client's under-
idate that client is in pain before implementation
standing of the PCA pump func-
tion.
3. Obtain an order to begin a PCA
infusion of fentanyl.
4. Ask the client to describe the
pain.
Page 2
, Kaplan NCLEX Readiness Exam
Kaplan NCLEX Readiness Exam Practice Questions, Answers
Study online at https://quizlet.com/_hlke1x
5. A pregnant woman receives an 1) Implementation: outcome not desired; no increase
epidural anesthetic. After adminis- in venous return
tration of the epidural anesthetic,
the client's blood pressure changes 2) Implementation: outcome not desired; will de-
from 120/84 to 94/50. Which action crease venous return
by the nurse is MOST appropriate?
3) CORRECT - Implementation: outcome desired; will
1. Place the client flat on her back. increase venous return and cardiac output; fetal pres-
2. Elevate the head of the bed 30 sure on inferior vena cava reduced
degrees.
4) Implementation: outcome not desired; elevation of
3. Place the client on her left side
legs will increase venous return, but fetal pressure on
with her legs flexed.
vena cava will prevent blood return to heart
4. Place the client supine with the
foot of the bed elevated.
6. A nursing order, "Increase fluid in- 1) CORRECT - Assessment: outcome priority; increased
take" is written for a client di- amounts of antidiuretic hormone secreted; urine out-
agnosed with dehydration. Which put decreased and concentrated
finding BEST indicates improving
fluid status? 2) Assessment: outcome not priority; indicates that
blood is hemoconcentrated
1. Urinary output of 1,500 mL in 24
hours. 3) Assessment: outcome not priority; normal intake is
2. Serum hematocrit 52%. 1,500 mL in 24 hours
3. Oral fluid intake of 900 mL in 24
4) Assessment: outcome not priority; normal BP is
hours.
120/80
4. Blood pressure of 100/82.
7. The nurse prepares to administer 1) Implementation: outcome not a problem; no inter-
the initial dose of oral enalapril (Va- action with ACE inhibitors; is an SSRI antidepressant
sotec) 20 mg in the morning. Which
medication should the nurse ques- 2) CORRECT - Implementation: outcome potential
Page 3
, Kaplan NCLEX Readiness Exam
Kaplan NCLEX Readiness Exam Practice Questions, Answers
Study online at https://quizlet.com/_hlke1x
tion giving to the client? problem; may promote significant diuresis; first dose
of ACE inhibitors increases risk of "first dose" phe-
1. 20 mg oral escitalopram (Celexa) nomenon due to vasodilation; combination of vasodi-
in the morning. lation and diuresis increases risk of orthostatic hy-
2. 40 mg oral furosemide (Lasix) in potension
the morning.
3. 300 mg of oral gabapentin (Neu- 3) Implementation: outcome not a problem; no inter-
rontin) twice daily. action; gabapentin classified as antiseizure medica-
4. 10 mg zolpidem (Ambien) at bed- tion; off-label use for neuropathic pain
time.
4) Implementation: outcome not a problem; is a hyp-
notic; no interaction with ACE inhibitors
8. The home care nurse visits a client 1) Assessment: outcome desired; risk of infection at
with a halo fixator traction device. pin sites; client should be taught signs of inflamma-
Which client statement MOST con- tion and infection
cerns the nurse?
2) Implementation: outcome desired; showers in-
crease risk of infection at pin sites
1. "My wife looks at the pin sites 3) CORRECT - Implementation: outcome not desired
every day." and may be a problem; client is not able to turn with
2. "I like to bathe in the tub." halo device; increases the risk of injury to self and
3. "I drove to the library yesterday." others
4. "I drink with a straw."
4) Implementation: outcome desired; difficulty ma-
nipulating cup or glass due to immobilized neck
9. The nurse cares for a client di- 1) CORRECT - Assessment: outcome desired; clients
agnosed with depression. Which with depression may have increased or decreased
statement by the client indicates sleep time
improvement?
2) Assessment: outcome not desired; lack of appetite
Page 4
