EXAM
Exam Solution ms
Kaplan NCLEX Readiness Exam 2026 A+ GRADE ASSUR ms ms ms ms ms ms ms
ED COMPLETE SOLUTIONS AND VERIFIED ANSWERS (8
ms ms ms ms ms ms
390D)
QUESTION 1 ms
A young adult brings a friend to the emergency department and states that the friend
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
has been using heroin. Which action by the nurse is the MOST appropriate? 1. Assess
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
pupil size and reactivity. 2. Assess oxygen saturation levels. 3. Palpate dorsalis pedis p
ms ms ms ms ms ms ms ms ms ms ms ms ms
ulses. 4. Ask the client if he knows today's date.
ms ms ms ms ms ms ms ms ms
ANSWER
1) Assessment: outcome not priority but may be appropriate; pinpoint pupils are a sign of heroin ov
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
erdose 2) CORRECT - ms ms ms
Assessment: outcome priority; shallow respirations seen; impaired alveolar gas exchange and possib
ms ms ms ms ms ms ms ms ms ms ms ms
le respiratory arrest 3) Assessment: outcome not priority; most important to assess airway and brea
ms ms ms ms ms ms ms ms ms ms ms ms ms ms
thing 4) Assessment: outcome not priority but may be appropriate; drowsiness and euphoria may be
ms ms ms ms ms ms ms ms ms ms ms ms ms ms
seen; not priority
ms ms ms
QUESTION 2 ms
The client tells the clinic nurse that the client is thinking about using nicotine polacril
ms ms ms ms ms ms ms ms ms ms ms ms ms ms
ex (Nicorette). Which question is MOST important for the nurse to ask? 1. "Have you t
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
ried other methods to stop smoking?" 2. "How long have you been smoking?" 3. "Have
ms ms ms ms ms ms ms ms ms ms ms ms ms ms
you ever had chest pain?" 4. "Do you have a partial dental bridge?"
ms ms ms ms ms ms ms ms ms ms ms ms ms
ANSWER
1) Assessment: outcome not priority but may be appropriate; can be asked as part of assessment 2)
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms m
Assessment: outcome not priority but may be appropriate; should be assessed for further teaching 3
s ms ms ms ms ms ms ms ms ms ms ms ms ms ms
) CORRECT -
ms ms
Assessment: outcome priority; action of nicotine is vasoconstriction; increases heart rate and myoca
ms ms ms ms ms ms ms ms ms ms ms ms ms
rdial oxygen consumption; increased risk of angina and myocardial infarction 4) Assessment: outcom
ms ms ms ms ms ms ms ms ms ms ms ms
e may be appropriate but not priority; gum is place between cheek and gums; may stain dental wor
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
k
,QUESTION 3 ms
A nursing order, "Increase fluid intake" is written for a client diagnosed with dehydra
ms ms ms ms ms ms ms ms ms ms ms ms ms
tion. Which finding BEST indicates improving fluid status? 1. Urinary output of 1,500
ms ms ms ms ms ms ms ms ms ms ms ms ms
mL in 24 hours. 2. Serum hematocrit 52%. 3. Oral fluid intake of 900 mL in 24 hours.
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms m
4. Blood pressure of 100/82.
s ms ms ms ms
ANSWER
1) CORRECT -
ms ms
Assessment: outcome priority; increased amounts of antidiuretic hormone secreted; urine output de
ms ms ms ms ms ms ms ms ms ms ms ms
creased and concentrated 2) Assessment: outcome not priority; indicates that blood is hemoconcentr
ms ms ms ms ms ms ms ms ms ms ms ms
ated 3) Assessment: outcome not priority; normal intake is 1,500 mL in 24 hours 4) Assessment: ou
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
tcome not priority; normal BP is 120/80
ms ms ms ms ms ms
QUESTION 4 ms
The nurse prepares to administer the initial dose of oral enalapril (Vasotec) 20 mg in
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
the morning. Which medication should the nurse question giving to the client? 1. 20
ms ms ms ms ms ms ms ms ms ms ms ms ms ms
mg oral escitalopram (Celexa) in the morning. 2. 40 mg oral furosemide (Lasix) in the
ms ms ms ms ms ms ms ms ms ms ms ms ms ms m
morning. 3. 300 mg of oral gabapentin (Neurontin) twice daily. 4. 10 mg zolpidem (A
s ms ms ms ms ms ms ms ms ms ms ms ms ms ms
mbien) at bedtime. ms ms
ANSWER
1) Implementation: outcome not a problem; no interaction with ACE inhibitors; is an SSRI antidepre
ms ms ms ms ms ms ms ms ms ms ms ms ms ms
ssant 2) CORRECT - ms ms ms
Implementation: outcome potential problem; may promote significant diuresis; first dose of ACE inh
ms ms ms ms ms ms ms ms ms ms ms ms ms
ibitors increases risk of "first dose" phenomenon due to vasodilation; combination of vasodilation an
ms ms ms ms ms ms ms ms ms ms ms ms ms
d diuresis increases risk of orthostatic hypotension 3) Implementation: outcome not a problem; no i
ms ms ms ms ms ms ms ms ms ms ms ms ms ms
nteraction; gabapentin classified as antiseizure medication; off-
ms ms ms ms ms ms
label use for neuropathic pain 4) Implementation: outcome not a problem; is a hypnotic; no interacti
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
on with ACE inhibitors
ms ms ms
QUESTION 5 ms
The home care nurse visits a client with a halo fixator traction device. Which client st
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
atement MOST concerns the nurse? 1. "My wife looks at the pin sites every day." 2. "I
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
like to bathe in the tub." 3. "I drove to the library yesterday." 4. "I drink with a straw.
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
"
ANSWER
1) Assessment: outcome desired; risk of infection at pin sites; client should be taught signs of inflam
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
mation and infection 2) Implementation: outcome desired; showers increase risk of infection at pin s
ms ms ms ms ms ms ms ms ms ms ms ms ms ms
ites 3) CORRECT -
ms ms ms
Implementation: outcome not desired and may be a problem; client is not able to turn with halo de
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
vice; increases the risk of injury to self and others 4) Implementation: outcome desired; difficulty m
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
anipulating cup or glass due to immobilized neck ms ms ms ms ms ms ms
, QUESTION 6 ms
The nurse cares for a client diagnosed with depression. Which statement by the client
ms ms ms ms ms ms ms ms ms ms ms ms ms m
indicates improvement? 1. "I have been sleeping 6 hours at night." 2. "I have lost 2 lb
s ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
s in the past week." 3. "Lately, I have trouble watching television." 4. "I have much les
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
s muscle tension now."
ms ms ms
ANSWER
1) CORRECT -
ms ms
Assessment: outcome desired; clients with depression may have increased or decreased sleep time
ms ms ms ms ms ms ms ms ms ms ms ms ms ms
2) Assessment: outcome not desired; lack of appetite is a frequent sign of depression 3) Assessment:
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
outcome not desired; lack of concentration is sign of depression 4) Assessment: outcome not desire
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
d; is a sign of anxiety
ms ms ms ms ms
QUESTION 7 ms
The nurse cares for a client diagnosed with Alzheimer's disease. The client is confused
ms ms ms ms ms ms ms ms ms ms ms ms ms
and incontinent of urine. What is the MOST important action for the nurse to take? 1.
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
Insert an indwelling urinary drainage catheter. 2. Perform intermittent catheterizatio
ms ms ms ms ms ms ms ms ms ms
n every 4 hours. 3. Offer the bedpan to the client every 2 hours. 4. Assist the client to
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms m
a bedside commode every 2 hours.
s ms ms ms ms ms
ANSWER
1) Implementation: outcome not desired; increases risk of infection; catheter-
ms ms ms ms ms ms ms ms ms
related infections are most common hospital-
ms ms ms ms ms
acquired infection 2) Implementation: outcome not desired; increases chance of infection 3) Impleme
ms ms ms ms ms ms ms ms ms ms ms ms
ntation: outcome appropriate but not priority; does not keep client independent and active 4) CORR
ms ms ms ms ms ms ms ms ms ms ms ms ms ms
ECT - Implementation: outcome desired; keeps client active and independent
ms ms ms ms ms ms ms ms ms
QUESTION 8 ms
The nurse prepares to administer gentamicin (Garamycin) to the 65-year-
ms ms ms ms ms ms ms ms ms
old client. Which is the MOST important action for the nurse to take prior to administ
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
ration of the medication? 1. Request a daily hemoglobin and hematocrit test. 2. Monit
ms ms ms ms ms ms ms ms ms ms ms ms ms
or the serum BUN and creatinine. 3. Request a highly-sensitive C-reactive protein (hs-
ms ms ms ms ms ms ms ms ms ms ms ms
CRP) test. 4. Monitor the erythrocyte sedimentation rate (ESR).
ms ms ms ms ms ms ms ms
ANSWER
1) Assessment: outcome not priority; may cause anemia, but not usually seen 2) CORRECT -
ms ms ms ms ms ms ms ms ms ms ms ms ms ms
Assessment: outcome priority; nephrotoxic; will see proteinuria, oliguria, hematuria, thirst, increased
ms ms ms ms ms ms ms ms ms ms ms
BUN, decreased creatine clearance 3) Assessment: outcome not priority; will be increased in inflam
ms ms ms ms ms ms ms ms ms ms ms ms ms ms
mation and rheumatoid arthritis 4) Assessment: outcome not priority; will be increased with any infl
ms ms ms ms ms ms ms ms ms ms ms ms ms ms
ammatory process ms
QUESTION 9 ms
Exam Solution ms
Kaplan NCLEX Readiness Exam 2026 A+ GRADE ASSUR ms ms ms ms ms ms ms
ED COMPLETE SOLUTIONS AND VERIFIED ANSWERS (8
ms ms ms ms ms ms
390D)
QUESTION 1 ms
A young adult brings a friend to the emergency department and states that the friend
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
has been using heroin. Which action by the nurse is the MOST appropriate? 1. Assess
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
pupil size and reactivity. 2. Assess oxygen saturation levels. 3. Palpate dorsalis pedis p
ms ms ms ms ms ms ms ms ms ms ms ms ms
ulses. 4. Ask the client if he knows today's date.
ms ms ms ms ms ms ms ms ms
ANSWER
1) Assessment: outcome not priority but may be appropriate; pinpoint pupils are a sign of heroin ov
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
erdose 2) CORRECT - ms ms ms
Assessment: outcome priority; shallow respirations seen; impaired alveolar gas exchange and possib
ms ms ms ms ms ms ms ms ms ms ms ms
le respiratory arrest 3) Assessment: outcome not priority; most important to assess airway and brea
ms ms ms ms ms ms ms ms ms ms ms ms ms ms
thing 4) Assessment: outcome not priority but may be appropriate; drowsiness and euphoria may be
ms ms ms ms ms ms ms ms ms ms ms ms ms ms
seen; not priority
ms ms ms
QUESTION 2 ms
The client tells the clinic nurse that the client is thinking about using nicotine polacril
ms ms ms ms ms ms ms ms ms ms ms ms ms ms
ex (Nicorette). Which question is MOST important for the nurse to ask? 1. "Have you t
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
ried other methods to stop smoking?" 2. "How long have you been smoking?" 3. "Have
ms ms ms ms ms ms ms ms ms ms ms ms ms ms
you ever had chest pain?" 4. "Do you have a partial dental bridge?"
ms ms ms ms ms ms ms ms ms ms ms ms ms
ANSWER
1) Assessment: outcome not priority but may be appropriate; can be asked as part of assessment 2)
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms m
Assessment: outcome not priority but may be appropriate; should be assessed for further teaching 3
s ms ms ms ms ms ms ms ms ms ms ms ms ms ms
) CORRECT -
ms ms
Assessment: outcome priority; action of nicotine is vasoconstriction; increases heart rate and myoca
ms ms ms ms ms ms ms ms ms ms ms ms ms
rdial oxygen consumption; increased risk of angina and myocardial infarction 4) Assessment: outcom
ms ms ms ms ms ms ms ms ms ms ms ms
e may be appropriate but not priority; gum is place between cheek and gums; may stain dental wor
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
k
,QUESTION 3 ms
A nursing order, "Increase fluid intake" is written for a client diagnosed with dehydra
ms ms ms ms ms ms ms ms ms ms ms ms ms
tion. Which finding BEST indicates improving fluid status? 1. Urinary output of 1,500
ms ms ms ms ms ms ms ms ms ms ms ms ms
mL in 24 hours. 2. Serum hematocrit 52%. 3. Oral fluid intake of 900 mL in 24 hours.
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms m
4. Blood pressure of 100/82.
s ms ms ms ms
ANSWER
1) CORRECT -
ms ms
Assessment: outcome priority; increased amounts of antidiuretic hormone secreted; urine output de
ms ms ms ms ms ms ms ms ms ms ms ms
creased and concentrated 2) Assessment: outcome not priority; indicates that blood is hemoconcentr
ms ms ms ms ms ms ms ms ms ms ms ms
ated 3) Assessment: outcome not priority; normal intake is 1,500 mL in 24 hours 4) Assessment: ou
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
tcome not priority; normal BP is 120/80
ms ms ms ms ms ms
QUESTION 4 ms
The nurse prepares to administer the initial dose of oral enalapril (Vasotec) 20 mg in
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
the morning. Which medication should the nurse question giving to the client? 1. 20
ms ms ms ms ms ms ms ms ms ms ms ms ms ms
mg oral escitalopram (Celexa) in the morning. 2. 40 mg oral furosemide (Lasix) in the
ms ms ms ms ms ms ms ms ms ms ms ms ms ms m
morning. 3. 300 mg of oral gabapentin (Neurontin) twice daily. 4. 10 mg zolpidem (A
s ms ms ms ms ms ms ms ms ms ms ms ms ms ms
mbien) at bedtime. ms ms
ANSWER
1) Implementation: outcome not a problem; no interaction with ACE inhibitors; is an SSRI antidepre
ms ms ms ms ms ms ms ms ms ms ms ms ms ms
ssant 2) CORRECT - ms ms ms
Implementation: outcome potential problem; may promote significant diuresis; first dose of ACE inh
ms ms ms ms ms ms ms ms ms ms ms ms ms
ibitors increases risk of "first dose" phenomenon due to vasodilation; combination of vasodilation an
ms ms ms ms ms ms ms ms ms ms ms ms ms
d diuresis increases risk of orthostatic hypotension 3) Implementation: outcome not a problem; no i
ms ms ms ms ms ms ms ms ms ms ms ms ms ms
nteraction; gabapentin classified as antiseizure medication; off-
ms ms ms ms ms ms
label use for neuropathic pain 4) Implementation: outcome not a problem; is a hypnotic; no interacti
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
on with ACE inhibitors
ms ms ms
QUESTION 5 ms
The home care nurse visits a client with a halo fixator traction device. Which client st
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
atement MOST concerns the nurse? 1. "My wife looks at the pin sites every day." 2. "I
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
like to bathe in the tub." 3. "I drove to the library yesterday." 4. "I drink with a straw.
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
"
ANSWER
1) Assessment: outcome desired; risk of infection at pin sites; client should be taught signs of inflam
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
mation and infection 2) Implementation: outcome desired; showers increase risk of infection at pin s
ms ms ms ms ms ms ms ms ms ms ms ms ms ms
ites 3) CORRECT -
ms ms ms
Implementation: outcome not desired and may be a problem; client is not able to turn with halo de
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
vice; increases the risk of injury to self and others 4) Implementation: outcome desired; difficulty m
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
anipulating cup or glass due to immobilized neck ms ms ms ms ms ms ms
, QUESTION 6 ms
The nurse cares for a client diagnosed with depression. Which statement by the client
ms ms ms ms ms ms ms ms ms ms ms ms ms m
indicates improvement? 1. "I have been sleeping 6 hours at night." 2. "I have lost 2 lb
s ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
s in the past week." 3. "Lately, I have trouble watching television." 4. "I have much les
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
s muscle tension now."
ms ms ms
ANSWER
1) CORRECT -
ms ms
Assessment: outcome desired; clients with depression may have increased or decreased sleep time
ms ms ms ms ms ms ms ms ms ms ms ms ms ms
2) Assessment: outcome not desired; lack of appetite is a frequent sign of depression 3) Assessment:
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
outcome not desired; lack of concentration is sign of depression 4) Assessment: outcome not desire
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
d; is a sign of anxiety
ms ms ms ms ms
QUESTION 7 ms
The nurse cares for a client diagnosed with Alzheimer's disease. The client is confused
ms ms ms ms ms ms ms ms ms ms ms ms ms
and incontinent of urine. What is the MOST important action for the nurse to take? 1.
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
Insert an indwelling urinary drainage catheter. 2. Perform intermittent catheterizatio
ms ms ms ms ms ms ms ms ms ms
n every 4 hours. 3. Offer the bedpan to the client every 2 hours. 4. Assist the client to
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms m
a bedside commode every 2 hours.
s ms ms ms ms ms
ANSWER
1) Implementation: outcome not desired; increases risk of infection; catheter-
ms ms ms ms ms ms ms ms ms
related infections are most common hospital-
ms ms ms ms ms
acquired infection 2) Implementation: outcome not desired; increases chance of infection 3) Impleme
ms ms ms ms ms ms ms ms ms ms ms ms
ntation: outcome appropriate but not priority; does not keep client independent and active 4) CORR
ms ms ms ms ms ms ms ms ms ms ms ms ms ms
ECT - Implementation: outcome desired; keeps client active and independent
ms ms ms ms ms ms ms ms ms
QUESTION 8 ms
The nurse prepares to administer gentamicin (Garamycin) to the 65-year-
ms ms ms ms ms ms ms ms ms
old client. Which is the MOST important action for the nurse to take prior to administ
ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms
ration of the medication? 1. Request a daily hemoglobin and hematocrit test. 2. Monit
ms ms ms ms ms ms ms ms ms ms ms ms ms
or the serum BUN and creatinine. 3. Request a highly-sensitive C-reactive protein (hs-
ms ms ms ms ms ms ms ms ms ms ms ms
CRP) test. 4. Monitor the erythrocyte sedimentation rate (ESR).
ms ms ms ms ms ms ms ms
ANSWER
1) Assessment: outcome not priority; may cause anemia, but not usually seen 2) CORRECT -
ms ms ms ms ms ms ms ms ms ms ms ms ms ms
Assessment: outcome priority; nephrotoxic; will see proteinuria, oliguria, hematuria, thirst, increased
ms ms ms ms ms ms ms ms ms ms ms
BUN, decreased creatine clearance 3) Assessment: outcome not priority; will be increased in inflam
ms ms ms ms ms ms ms ms ms ms ms ms ms ms
mation and rheumatoid arthritis 4) Assessment: outcome not priority; will be increased with any infl
ms ms ms ms ms ms ms ms ms ms ms ms ms ms
ammatory process ms
QUESTION 9 ms
