KAPLAN DIAGNOSTIC COMPLETE
EXAM VERIFIED QUESTIONS &
ANSWERS WITH DETAILED
RATIONALES NCLEX-RN
Questions 1–10: Medical-Surgical & Prioritization
1. A client is admitted to the emergency department with deep partial-
thickness burns of the arms and chest sustained in a house fire. The client is
very restless and anxious. Which action should the nurse take FIRST?
• ,,,ANSWER,,,: Listen to breath sounds
• Rationale: In a burn patient, restlessness and anxiety are often early signs of
hypoxia or airway compromise due to smoke inhalation. The priority action is
to assess the airway and breathing (the "A" and "B" of the ABCs) before any
other intervention.
2. The clinic nurse cares for a client diagnosed with irritable bowel syndrome. It
is MOST important for the nurse to include which of the following statements
to the client?
• ,,,ANSWER,,,: "It would be helpful to increase your intake of whole grains,
raw fruits, and vegetables."
• Rationale: A high-fiber diet helps regulate bowel function in IBS. Whole
grains, raw fruits, and vegetables provide the necessary fiber to manage both
constipation and diarrhea symptoms associated with IBS.
,3. A patient is admitted with a diagnosis of acute myocardial infarction. Which
action should the nurse take first?
• ,,,ANSWER,,,: Administer oxygen via nasal cannula
• Rationale: Following the ABCs (Airway, Breathing, Circulation), providing
oxygen takes priority to improve myocardial tissue perfusion immediately.
4. A client is eight hours postoperative after a transurethral resection of the
prostate (TURP). Which of these observations, if noted by a nurse, indicates a
complication?
• ,,,ANSWER,,,: (The preview cuts off, but TURP complications include bright
red bleeding with clots, continuous bladder spasms unrelieved by
medication, and fever)
5. A client has a tracheostomy. The nurse determines that the priority nursing
intervention for maintaining a patent airway is to:
• ,,,ANSWER,,,: Maintain the inner cannula cleanliness
• Rationale: Maintaining a clean inner cannula is essential to prevent mucus
plugging and airway obstruction. While sterile technique is important for
initial insertion and suctioning, the priority is ensuring patency.
6. A charge nurse is making client assignments for a medical-surgical unit.
Which client should be assigned to the most experienced registered nurse
(RN)?
• ,,,ANSWER,,,: A 70-year-old with new-onset atrial fibrillation, started on an
IV heparin drip 2 hours ago
• Rationale: Client assignments should be based on acuity and staff
competency. The client on a heparin drip is unstable, requires frequent
monitoring (aPTT levels), and has a high risk for complications (bleeding).
,7. A nurse is caring for a client who has a diagnosis of Clostridioides difficile (C.
diff) infection. Which action by the nursing assistant requires the nurse to
intervene immediately?
• ,,,ANSWER,,,: The assistant uses an alcohol-based hand rub after removing
gloves
• Rationale: C. diff spores are resistant to alcohol-based hand rubs. The
proper hand hygiene method is to wash hands with soap and water, using
friction, to physically remove the spores.
8. A nurse is assigned to care for four clients. Which client should the nurse
assess first?
• ,,,ANSWER,,,: A client with an abdominal wound vac reporting 10/10 pain
after pain medication
• Rationale: A client with a wound vac reporting severe pain (10/10) after
receiving pain medication requires immediate reassessment to evaluate the
effectiveness of the pain regimen and rule out complications.
9. After gastric lavage is completed, it is MOST important for the nurse to take
which of the following actions?
• ,,,ANSWER,,,: Ask the patient to hold his breath as the tube is removed
• Rationale: During removal of a nasogastric tube used for lavage, asking the
patient to hold his breath prevents aspiration of any residual stomach
contents.
10. A patient is prescribed Warfarin. Which lab value should the nurse monitor
to evaluate the effectiveness of the medication?
• ,,,ANSWER,,,: INR (International Normalized Ratio)
• Rationale: INR is the standard measurement used to monitor the
effectiveness of anticoagulant therapy like Warfarin.
, Questions 11–20: Pharmacology & Delegation
11. A patient is prescribed atorvastatin (Lipitor) for hyperlipidemia. Which
statement by the patient indicates a need for further teaching?
• ,,,ANSWER,,,: "I can continue drinking grapefruit juice with my breakfast."
• Rationale: Atorvastatin, like other statins, is metabolized by the CYP3A4
enzyme system. Grapefruit juice inhibits this enzyme, leading to increased
blood levels of the drug and a higher risk of adverse effects like myopathy
and rhabdomyolysis.
12. The nurse prepares to administer digoxin 0.125 mg to a patient with heart
failure. Which assessment finding would cause the nurse to withhold the
medication and contact the healthcare provider?
• ,,,ANSWER,,,: Heart rate of 54 beats per minute
• Rationale: A key nursing responsibility is checking the apical pulse for one
full minute before administration. The general guideline is to withhold the
dose if the adult pulse is below 60 bpm and notify the provider, as
bradycardia can indicate toxicity.
13. A client with type 1 diabetes mellitus is found unconscious. Which action
should the nurse take first?
• ,,,ANSWER,,,: Open the airway and check breathing
• Rationale: The ABCs always come first. Even if hypoglycemia is suspected,
the nurse must first ensure the client has a patent airway and is breathing
before any diabetes-specific intervention.
EXAM VERIFIED QUESTIONS &
ANSWERS WITH DETAILED
RATIONALES NCLEX-RN
Questions 1–10: Medical-Surgical & Prioritization
1. A client is admitted to the emergency department with deep partial-
thickness burns of the arms and chest sustained in a house fire. The client is
very restless and anxious. Which action should the nurse take FIRST?
• ,,,ANSWER,,,: Listen to breath sounds
• Rationale: In a burn patient, restlessness and anxiety are often early signs of
hypoxia or airway compromise due to smoke inhalation. The priority action is
to assess the airway and breathing (the "A" and "B" of the ABCs) before any
other intervention.
2. The clinic nurse cares for a client diagnosed with irritable bowel syndrome. It
is MOST important for the nurse to include which of the following statements
to the client?
• ,,,ANSWER,,,: "It would be helpful to increase your intake of whole grains,
raw fruits, and vegetables."
• Rationale: A high-fiber diet helps regulate bowel function in IBS. Whole
grains, raw fruits, and vegetables provide the necessary fiber to manage both
constipation and diarrhea symptoms associated with IBS.
,3. A patient is admitted with a diagnosis of acute myocardial infarction. Which
action should the nurse take first?
• ,,,ANSWER,,,: Administer oxygen via nasal cannula
• Rationale: Following the ABCs (Airway, Breathing, Circulation), providing
oxygen takes priority to improve myocardial tissue perfusion immediately.
4. A client is eight hours postoperative after a transurethral resection of the
prostate (TURP). Which of these observations, if noted by a nurse, indicates a
complication?
• ,,,ANSWER,,,: (The preview cuts off, but TURP complications include bright
red bleeding with clots, continuous bladder spasms unrelieved by
medication, and fever)
5. A client has a tracheostomy. The nurse determines that the priority nursing
intervention for maintaining a patent airway is to:
• ,,,ANSWER,,,: Maintain the inner cannula cleanliness
• Rationale: Maintaining a clean inner cannula is essential to prevent mucus
plugging and airway obstruction. While sterile technique is important for
initial insertion and suctioning, the priority is ensuring patency.
6. A charge nurse is making client assignments for a medical-surgical unit.
Which client should be assigned to the most experienced registered nurse
(RN)?
• ,,,ANSWER,,,: A 70-year-old with new-onset atrial fibrillation, started on an
IV heparin drip 2 hours ago
• Rationale: Client assignments should be based on acuity and staff
competency. The client on a heparin drip is unstable, requires frequent
monitoring (aPTT levels), and has a high risk for complications (bleeding).
,7. A nurse is caring for a client who has a diagnosis of Clostridioides difficile (C.
diff) infection. Which action by the nursing assistant requires the nurse to
intervene immediately?
• ,,,ANSWER,,,: The assistant uses an alcohol-based hand rub after removing
gloves
• Rationale: C. diff spores are resistant to alcohol-based hand rubs. The
proper hand hygiene method is to wash hands with soap and water, using
friction, to physically remove the spores.
8. A nurse is assigned to care for four clients. Which client should the nurse
assess first?
• ,,,ANSWER,,,: A client with an abdominal wound vac reporting 10/10 pain
after pain medication
• Rationale: A client with a wound vac reporting severe pain (10/10) after
receiving pain medication requires immediate reassessment to evaluate the
effectiveness of the pain regimen and rule out complications.
9. After gastric lavage is completed, it is MOST important for the nurse to take
which of the following actions?
• ,,,ANSWER,,,: Ask the patient to hold his breath as the tube is removed
• Rationale: During removal of a nasogastric tube used for lavage, asking the
patient to hold his breath prevents aspiration of any residual stomach
contents.
10. A patient is prescribed Warfarin. Which lab value should the nurse monitor
to evaluate the effectiveness of the medication?
• ,,,ANSWER,,,: INR (International Normalized Ratio)
• Rationale: INR is the standard measurement used to monitor the
effectiveness of anticoagulant therapy like Warfarin.
, Questions 11–20: Pharmacology & Delegation
11. A patient is prescribed atorvastatin (Lipitor) for hyperlipidemia. Which
statement by the patient indicates a need for further teaching?
• ,,,ANSWER,,,: "I can continue drinking grapefruit juice with my breakfast."
• Rationale: Atorvastatin, like other statins, is metabolized by the CYP3A4
enzyme system. Grapefruit juice inhibits this enzyme, leading to increased
blood levels of the drug and a higher risk of adverse effects like myopathy
and rhabdomyolysis.
12. The nurse prepares to administer digoxin 0.125 mg to a patient with heart
failure. Which assessment finding would cause the nurse to withhold the
medication and contact the healthcare provider?
• ,,,ANSWER,,,: Heart rate of 54 beats per minute
• Rationale: A key nursing responsibility is checking the apical pulse for one
full minute before administration. The general guideline is to withhold the
dose if the adult pulse is below 60 bpm and notify the provider, as
bradycardia can indicate toxicity.
13. A client with type 1 diabetes mellitus is found unconscious. Which action
should the nurse take first?
• ,,,ANSWER,,,: Open the airway and check breathing
• Rationale: The ABCs always come first. Even if hypoglycemia is suspected,
the nurse must first ensure the client has a patent airway and is breathing
before any diabetes-specific intervention.
