Kaplan Readiness Exam Predictor Test | 180
NCLEX Questions and Detailed Rationales
1. The charge nurse is making assignments on a medical-surgical unit. Which
client should be assigned to the most experienced RN?
A. A client with pneumonia requiring IV antibiotics every 6 hours.
B. A client with a fractured hip who is 1 day post-operative.
C. A client with end-stage renal disease who is exhibiting confusion and
twitching.
D. A client with a new diagnosis of hypertension requiring dietary teaching.
Correct Answer: C
Rationale: The client with ESRD exhibiting confusion and twitching is displaying
signs of severe uremia or electrolyte imbalances (like hyperkalemia or
hypocalcemia), which can rapidly progress to seizures or cardiac arrest. This client
requires the most experienced RN for complex assessment. The other options are
stable and can be delegated to less experienced nurses or LPNs.
2. A nurse is caring for four clients. Which client should the nurse assess FIRST?
A. A client with an NG tube who has vomited 50 mL of greenish fluid.
B. A client with a new colostomy who is reporting abdominal cramping.
C. A client with a hip replacement who is reporting incisional pain of 6/10.
D. A client with a chest tube who has continuous bubbling in the water seal
chamber.
,Correct Answer: D
Rationale: Continuous bubbling in the water seal chamber indicates an air leak,
which can lead to a tension pneumothorax or complete lung collapse. This is a life-
threatening airway/breathing issue. Vomiting with an NG tube (A) requires
checking placement, but it is not immediately life-threatening. Pain (C) and
cramping (B) are important but lower priority.
3. The nurse receives a telephone order from a healthcare provider for
"Morphine sulfate 4 mg IV push every 2 hours PRN for severe pain." Which
action should the nurse take FIRST?
A. Administer the medication as ordered.
B. Ask the provider to clarify the administration rate.
C. Repeat the order back to the provider.
D. Document the order in the electronic medical record.
Correct Answer: B
Rationale: An IV push order must include the rate of administration (e.g., "over 2-5
minutes") to prevent severe respiratory depression and hypotension. While
repeating back (C) is part of telephone orders, the FIRST action is to recognize the
missing component and obtain clarification before administration.
4. An RN is delegating tasks to an unlicensed assistive personnel (UAP). Which
task is appropriate to delegate?
A. Performing a sterile dressing change on a surgical wound.
B. Assessing a client's lung sounds for crackles.
C. Obtaining a clean-catch urine specimen from a client.
D. Teaching a client how to use an incentive spirometer.
,Correct Answer: C
Rationale: Obtaining a clean-catch urine specimen is a non-invasive, standard
technical skill that falls within the UAP's scope of practice. Assessments (B), sterile
procedures (A), and teaching (D) require the licensed nurse's clinical judgment and
cannot be delegated.
5. A client is receiving a blood transfusion of packed red blood cells. Fifteen
minutes after the transfusion starts, the client reports low back pain and chills.
What is the priority nursing action?
A. Slow the transfusion rate and monitor the client.
B. Stop the transfusion and keep the IV line open with normal saline.
C. Administer diphenhydramine (Benadryl) as a pre-medication.
D. Notify the blood bank of a suspected reaction.
Correct Answer: B
Rationale: Low back pain, chills, and flushing are signs of an acute hemolytic
transfusion reaction (ABO incompatibility). The priority is to STOP the transfusion
immediately to prevent further hemolysis and acute kidney injury, but KEEP the IV
line patent with normal saline (not dextrose) to have access for emergency
medications.
6. A client with a history of atrial fibrillation is prescribed warfarin (Coumadin).
The client's INR is 4.8. What should the nurse do FIRST?
A. Administer the next scheduled dose of warfarin.
B. Hold the warfarin and notify the healthcare provider.
C. Administer vitamin K orally immediately.
D. Increase the warfarin dose.
, Correct Answer: B
Rationale: The therapeutic INR for atrial fibrillation is 2.0-3.0. An INR of 4.8 is
supratherapeutic and places the client at high risk for bleeding. The warfarin
should be held, and the provider notified. Vitamin K is given if there is active
bleeding or INR is dangerously high (>5.0).
7. A client with a severe head injury has a Glasgow Coma Scale (GCS) score of 6
(E1, V1, M4). Which nursing action is most important?
A. Stimulate the client to improve responsiveness.
B. Turn the client every 2 hours.
C. Prepare for immediate intubation.
D. Reassess the GCS in 30 minutes.
Correct Answer: C
Rationale: A GCS score of 8 or less indicates a severe brain injury and coma. The
client cannot protect their airway. The priority is to prepare for immediate
intubation to maintain airway patency and prevent aspiration. Airway always
comes first.
8. A client with a new tracheostomy is being discharged. Which statement by the
client indicates a need for further teaching?
A. "I should keep the tracheostomy tube ties snug but not tight."
B. "I will humidify the air in my home to prevent secretions from drying."
C. "I can go swimming as long as I cover my stoma with a waterproof dressing."
D. "I should have a suction kit and extra tracheostomy tube at home."
Correct Answer: C
Rationale: Clients with a tracheostomy should NEVER swim or submerge their
stoma in water due to the high risk of aspiration and drowning. Covering it with a
NCLEX Questions and Detailed Rationales
1. The charge nurse is making assignments on a medical-surgical unit. Which
client should be assigned to the most experienced RN?
A. A client with pneumonia requiring IV antibiotics every 6 hours.
B. A client with a fractured hip who is 1 day post-operative.
C. A client with end-stage renal disease who is exhibiting confusion and
twitching.
D. A client with a new diagnosis of hypertension requiring dietary teaching.
Correct Answer: C
Rationale: The client with ESRD exhibiting confusion and twitching is displaying
signs of severe uremia or electrolyte imbalances (like hyperkalemia or
hypocalcemia), which can rapidly progress to seizures or cardiac arrest. This client
requires the most experienced RN for complex assessment. The other options are
stable and can be delegated to less experienced nurses or LPNs.
2. A nurse is caring for four clients. Which client should the nurse assess FIRST?
A. A client with an NG tube who has vomited 50 mL of greenish fluid.
B. A client with a new colostomy who is reporting abdominal cramping.
C. A client with a hip replacement who is reporting incisional pain of 6/10.
D. A client with a chest tube who has continuous bubbling in the water seal
chamber.
,Correct Answer: D
Rationale: Continuous bubbling in the water seal chamber indicates an air leak,
which can lead to a tension pneumothorax or complete lung collapse. This is a life-
threatening airway/breathing issue. Vomiting with an NG tube (A) requires
checking placement, but it is not immediately life-threatening. Pain (C) and
cramping (B) are important but lower priority.
3. The nurse receives a telephone order from a healthcare provider for
"Morphine sulfate 4 mg IV push every 2 hours PRN for severe pain." Which
action should the nurse take FIRST?
A. Administer the medication as ordered.
B. Ask the provider to clarify the administration rate.
C. Repeat the order back to the provider.
D. Document the order in the electronic medical record.
Correct Answer: B
Rationale: An IV push order must include the rate of administration (e.g., "over 2-5
minutes") to prevent severe respiratory depression and hypotension. While
repeating back (C) is part of telephone orders, the FIRST action is to recognize the
missing component and obtain clarification before administration.
4. An RN is delegating tasks to an unlicensed assistive personnel (UAP). Which
task is appropriate to delegate?
A. Performing a sterile dressing change on a surgical wound.
B. Assessing a client's lung sounds for crackles.
C. Obtaining a clean-catch urine specimen from a client.
D. Teaching a client how to use an incentive spirometer.
,Correct Answer: C
Rationale: Obtaining a clean-catch urine specimen is a non-invasive, standard
technical skill that falls within the UAP's scope of practice. Assessments (B), sterile
procedures (A), and teaching (D) require the licensed nurse's clinical judgment and
cannot be delegated.
5. A client is receiving a blood transfusion of packed red blood cells. Fifteen
minutes after the transfusion starts, the client reports low back pain and chills.
What is the priority nursing action?
A. Slow the transfusion rate and monitor the client.
B. Stop the transfusion and keep the IV line open with normal saline.
C. Administer diphenhydramine (Benadryl) as a pre-medication.
D. Notify the blood bank of a suspected reaction.
Correct Answer: B
Rationale: Low back pain, chills, and flushing are signs of an acute hemolytic
transfusion reaction (ABO incompatibility). The priority is to STOP the transfusion
immediately to prevent further hemolysis and acute kidney injury, but KEEP the IV
line patent with normal saline (not dextrose) to have access for emergency
medications.
6. A client with a history of atrial fibrillation is prescribed warfarin (Coumadin).
The client's INR is 4.8. What should the nurse do FIRST?
A. Administer the next scheduled dose of warfarin.
B. Hold the warfarin and notify the healthcare provider.
C. Administer vitamin K orally immediately.
D. Increase the warfarin dose.
, Correct Answer: B
Rationale: The therapeutic INR for atrial fibrillation is 2.0-3.0. An INR of 4.8 is
supratherapeutic and places the client at high risk for bleeding. The warfarin
should be held, and the provider notified. Vitamin K is given if there is active
bleeding or INR is dangerously high (>5.0).
7. A client with a severe head injury has a Glasgow Coma Scale (GCS) score of 6
(E1, V1, M4). Which nursing action is most important?
A. Stimulate the client to improve responsiveness.
B. Turn the client every 2 hours.
C. Prepare for immediate intubation.
D. Reassess the GCS in 30 minutes.
Correct Answer: C
Rationale: A GCS score of 8 or less indicates a severe brain injury and coma. The
client cannot protect their airway. The priority is to prepare for immediate
intubation to maintain airway patency and prevent aspiration. Airway always
comes first.
8. A client with a new tracheostomy is being discharged. Which statement by the
client indicates a need for further teaching?
A. "I should keep the tracheostomy tube ties snug but not tight."
B. "I will humidify the air in my home to prevent secretions from drying."
C. "I can go swimming as long as I cover my stoma with a waterproof dressing."
D. "I should have a suction kit and extra tracheostomy tube at home."
Correct Answer: C
Rationale: Clients with a tracheostomy should NEVER swim or submerge their
stoma in water due to the high risk of aspiration and drowning. Covering it with a
