Kaplan NCLEX Readiness Exam (Latest
Updates) Questions and
Answers {Grade A} 100% Correct (Verified
Answers)
The nurse cares for clients in the antepartum clinic. Which client should the nurse see
FIRST?
1. An 18-year-old multigravida client at 28 weeks gestation with a positive indirect
Coombs' test.
2. A 24-year-old multigravida client at 32 weeks gestation with moderate facial
edema.
3. A 30-year-old client at 26 weeks gestation with bilateral yellow breast exudate.
4. A 43-year-old primigravida client at 18 weeks of gestation reporting an absence of
fetal movement. 1) Outcome not priority; indicates that Rh antibodies present; needs
further investigation
2) - correct answer - Outcome priority; indicates pre-eclampsia; requires immediate
evaluation; is at risk for complications
,3) Outcome not priority; colostrum may leak from breast during pregnancy; normal
finding
4) Outcome not priority; normal finding; quickening doesn't occur before 18 weeks in
primagravidas; 20 weeks in multigravidas
The nurse instructs a client about include digoxin (Lanoxin), furosemide (Lasix),
spironolactone (Aldactone), and a low-sodium diet. Which statement by the client
indicates the need for further instruction?
1. "I should weigh myself every morning and call the health care provider if I gain more
than a couple of pounds in a few days."
2. "I should call the health care provider immediately if I start to feel nauseated or
have difficulty breathing with normal activities."
3. "I plan to use salt substitutes now that I have to limit my sodium intake."
4. "I should read food and nonprescription medication labels to check the ingredients."
1) Implementation: outcome desired; would indicate fluid retention
,2) Implementation: outcome desired; symptoms of digitalis toxicity, CHF
3) - correct answer - Implementation: outcome not desired; salt substitutes contain
potassium; spironolactone is a potassium-sparing diuretic
4) Implementation: outcome desired; some medications may contain sodium and
potassium
The nurse cares for a client scheduled for a femoral popliteal bypass procedure. When
the nurse approaches the client with the informed consent form, the client says, "I
don't need to talk to anybody about this procedure. I already know everything I need to
know about it." Which response by the nurse is BEST?
1. "After I explain the operation to you, both of us will sign the form for legal purposes
and it will be placed in your chart."
2. "Tell me what the healthcare provider told you about the risks and benefits of this
operation."
, 3. "Can I answer any questions that you have about the procedure?"
4. "You should read all these materials to be sure that you understand everything
about this procedure." 1) Implementation: outcome not desired; nurse should not
explain the procedure; the health care provider doing the procedure should explain the
risks and benefits
2) - correct answer - Assessment: outcome desired; nurse should determine if client
understands risks and benefits of the procedure before the client and nurse sign the
informed consent form
3) Implementation: outcome not desired; yes/no question non-therapeutic response
4) Implementation: outcome desired but not priority; reading materials do not ensure
that client understands risks and benefits of the procedure
A man scheduled for a vasectomy tells the nurse that he and his wife are involved in a
monogamous relationship. Which statement by the nurse is BEST?
Updates) Questions and
Answers {Grade A} 100% Correct (Verified
Answers)
The nurse cares for clients in the antepartum clinic. Which client should the nurse see
FIRST?
1. An 18-year-old multigravida client at 28 weeks gestation with a positive indirect
Coombs' test.
2. A 24-year-old multigravida client at 32 weeks gestation with moderate facial
edema.
3. A 30-year-old client at 26 weeks gestation with bilateral yellow breast exudate.
4. A 43-year-old primigravida client at 18 weeks of gestation reporting an absence of
fetal movement. 1) Outcome not priority; indicates that Rh antibodies present; needs
further investigation
2) - correct answer - Outcome priority; indicates pre-eclampsia; requires immediate
evaluation; is at risk for complications
,3) Outcome not priority; colostrum may leak from breast during pregnancy; normal
finding
4) Outcome not priority; normal finding; quickening doesn't occur before 18 weeks in
primagravidas; 20 weeks in multigravidas
The nurse instructs a client about include digoxin (Lanoxin), furosemide (Lasix),
spironolactone (Aldactone), and a low-sodium diet. Which statement by the client
indicates the need for further instruction?
1. "I should weigh myself every morning and call the health care provider if I gain more
than a couple of pounds in a few days."
2. "I should call the health care provider immediately if I start to feel nauseated or
have difficulty breathing with normal activities."
3. "I plan to use salt substitutes now that I have to limit my sodium intake."
4. "I should read food and nonprescription medication labels to check the ingredients."
1) Implementation: outcome desired; would indicate fluid retention
,2) Implementation: outcome desired; symptoms of digitalis toxicity, CHF
3) - correct answer - Implementation: outcome not desired; salt substitutes contain
potassium; spironolactone is a potassium-sparing diuretic
4) Implementation: outcome desired; some medications may contain sodium and
potassium
The nurse cares for a client scheduled for a femoral popliteal bypass procedure. When
the nurse approaches the client with the informed consent form, the client says, "I
don't need to talk to anybody about this procedure. I already know everything I need to
know about it." Which response by the nurse is BEST?
1. "After I explain the operation to you, both of us will sign the form for legal purposes
and it will be placed in your chart."
2. "Tell me what the healthcare provider told you about the risks and benefits of this
operation."
, 3. "Can I answer any questions that you have about the procedure?"
4. "You should read all these materials to be sure that you understand everything
about this procedure." 1) Implementation: outcome not desired; nurse should not
explain the procedure; the health care provider doing the procedure should explain the
risks and benefits
2) - correct answer - Assessment: outcome desired; nurse should determine if client
understands risks and benefits of the procedure before the client and nurse sign the
informed consent form
3) Implementation: outcome not desired; yes/no question non-therapeutic response
4) Implementation: outcome desired but not priority; reading materials do not ensure
that client understands risks and benefits of the procedure
A man scheduled for a vasectomy tells the nurse that he and his wife are involved in a
monogamous relationship. Which statement by the nurse is BEST?
