Kaplan Integrated Exam
Fundamentals D NGN ACTUAL FINAL
EXAM QUESTIONS AND
ANWERS(NGN)|WELL
STRUCTURED|100 %PASS
1–10: Fundamentals & Safety
1. A client newly diagnosed with heart failure reports shortness of breath when
lying flat. Which nursing action is most appropriate?
Answer: Elevate the head of the bed to 45–60 degrees.
Rationale: Orthopnea (dyspnea when supine) is common in HF. Elevating the
HOB reduces venous return and pulmonary congestion. High-Fowler’s position
improves lung expansion.
2. The nurse notes a client’s oxygen saturation is 88% on room air. The client is
alert. What is the priority action?
Answer: Apply supplemental oxygen via nasal cannula at 2 L/min.
Rationale: SpO2 < 90% indicates hypoxemia. Oxygen is the first intervention.
Later, assess cause (e.g., pneumonia, COPD).
3. A postoperative client has a prescription for enoxaparin (Lovenox). Which
technique is correct for administration?
Answer: Inject subcutaneously into the abdomen, pinch skin fold, do not aspirate.
Rationale: Enoxaparin is a low-molecular-weight heparin given subcut in the
abdomen to prevent DVT. Aspiration can cause bleeding/bruising.
,4. A nurse is preparing to insert a urinary catheter. Which action maintains aseptic
technique?
Answer: Keep the sterile catheter within the sterile field and use sterile gloves.
Rationale: Catheter insertion requires sterile technique to prevent CAUTI. The
outer package is not sterile.
5. A client on fall precautions needs to use the bathroom. What should the nurse
do first?
Answer: Assess the client’s ability to stand and ambulate safely.
Rationale: Individualized assessment determines need for assistance, bedpan, or
portable commode. Never assume.
6. The nurse is teaching a client about using a cane. Which statement indicates
correct understanding?
Answer: “I will hold the cane on my stronger side.”
Rationale: Cane is held on the strong side to offload the weak leg. Advance cane
and weak leg together, then strong leg.
7. A client with a nasogastric tube to low intermittent suction has an order for oral
care. What is the priority?
Answer: Provide frequent mouth care and apply water-soluble lubricant to lips.
Rationale: NG tube bypasses mouth, leading to dry mucous membranes. Oral
care every 2–4 hours prevents cracking and infection.
8. The nurse observes a reddened area on a client’s sacrum that does not blanch.
What is the correct stage of pressure injury?
Answer: Stage 1 pressure injury.
Rationale: Non-blanchable erythema over intact skin defines Stage 1. Stage 2 has
partial thickness skin loss.
, 9. A client with a tracheostomy tube has thick, dried secretions around the stoma.
Which action should the nurse perform first?
Answer: Instill 3–5 mL of normal saline into the tracheostomy.
Rationale: Saline loosens thick secretions before suctioning. Then suction using
sterile technique.
10. The nurse is caring for a client with Clostridioides difficile. Which infection
control precaution is essential?
Answer: Use soap and water for hand hygiene; alcohol gel is ineffective.
Rationale: C. diff spores are not killed by alcohol. Only mechanical washing with
soap and water removes spores.
11–20: Pharmacology & Medication Administration
11. A client is prescribed digoxin 0.25 mg daily. Which finding requires
withholding the medication?
Answer: Apical pulse 52 bpm and client reports nausea and yellow vision.
Rationale: Digoxin toxicity causes bradycardia, GI symptoms, and visual changes.
Hold dose and notify provider.
12. The nurse administers furosemide (Lasix) 40 mg IV push. Which lab value is
most important to monitor?
Answer: Serum potassium.
Rationale: Furosemide is a loop diuretic that causes hypokalemia, increasing risk
for dysrhythmias, especially with digoxin.
Fundamentals D NGN ACTUAL FINAL
EXAM QUESTIONS AND
ANWERS(NGN)|WELL
STRUCTURED|100 %PASS
1–10: Fundamentals & Safety
1. A client newly diagnosed with heart failure reports shortness of breath when
lying flat. Which nursing action is most appropriate?
Answer: Elevate the head of the bed to 45–60 degrees.
Rationale: Orthopnea (dyspnea when supine) is common in HF. Elevating the
HOB reduces venous return and pulmonary congestion. High-Fowler’s position
improves lung expansion.
2. The nurse notes a client’s oxygen saturation is 88% on room air. The client is
alert. What is the priority action?
Answer: Apply supplemental oxygen via nasal cannula at 2 L/min.
Rationale: SpO2 < 90% indicates hypoxemia. Oxygen is the first intervention.
Later, assess cause (e.g., pneumonia, COPD).
3. A postoperative client has a prescription for enoxaparin (Lovenox). Which
technique is correct for administration?
Answer: Inject subcutaneously into the abdomen, pinch skin fold, do not aspirate.
Rationale: Enoxaparin is a low-molecular-weight heparin given subcut in the
abdomen to prevent DVT. Aspiration can cause bleeding/bruising.
,4. A nurse is preparing to insert a urinary catheter. Which action maintains aseptic
technique?
Answer: Keep the sterile catheter within the sterile field and use sterile gloves.
Rationale: Catheter insertion requires sterile technique to prevent CAUTI. The
outer package is not sterile.
5. A client on fall precautions needs to use the bathroom. What should the nurse
do first?
Answer: Assess the client’s ability to stand and ambulate safely.
Rationale: Individualized assessment determines need for assistance, bedpan, or
portable commode. Never assume.
6. The nurse is teaching a client about using a cane. Which statement indicates
correct understanding?
Answer: “I will hold the cane on my stronger side.”
Rationale: Cane is held on the strong side to offload the weak leg. Advance cane
and weak leg together, then strong leg.
7. A client with a nasogastric tube to low intermittent suction has an order for oral
care. What is the priority?
Answer: Provide frequent mouth care and apply water-soluble lubricant to lips.
Rationale: NG tube bypasses mouth, leading to dry mucous membranes. Oral
care every 2–4 hours prevents cracking and infection.
8. The nurse observes a reddened area on a client’s sacrum that does not blanch.
What is the correct stage of pressure injury?
Answer: Stage 1 pressure injury.
Rationale: Non-blanchable erythema over intact skin defines Stage 1. Stage 2 has
partial thickness skin loss.
, 9. A client with a tracheostomy tube has thick, dried secretions around the stoma.
Which action should the nurse perform first?
Answer: Instill 3–5 mL of normal saline into the tracheostomy.
Rationale: Saline loosens thick secretions before suctioning. Then suction using
sterile technique.
10. The nurse is caring for a client with Clostridioides difficile. Which infection
control precaution is essential?
Answer: Use soap and water for hand hygiene; alcohol gel is ineffective.
Rationale: C. diff spores are not killed by alcohol. Only mechanical washing with
soap and water removes spores.
11–20: Pharmacology & Medication Administration
11. A client is prescribed digoxin 0.25 mg daily. Which finding requires
withholding the medication?
Answer: Apical pulse 52 bpm and client reports nausea and yellow vision.
Rationale: Digoxin toxicity causes bradycardia, GI symptoms, and visual changes.
Hold dose and notify provider.
12. The nurse administers furosemide (Lasix) 40 mg IV push. Which lab value is
most important to monitor?
Answer: Serum potassium.
Rationale: Furosemide is a loop diuretic that causes hypokalemia, increasing risk
for dysrhythmias, especially with digoxin.
