Kaplan RN Readiness Exit Exam | 180 NCLEX
Predictor Questions and Rationales
1. The nurse is caring for a client with a complete heart block (third-degree AV
block). Which finding requires immediate intervention?
A. Heart rate of 48 beats/min
B. Blood pressure of 110/68 mmHg
C. Client reports feeling dizzy and lightheaded
D. Occasional premature ventricular contractions (PVCs)
Correct Answer: C
Rationale: Complete heart block can cause severe bradycardia and decreased
cardiac output. Dizziness and lightheadedness indicate cerebral hypoperfusion and
may precede syncope or cardiac arrest. This requires immediate intervention
(pacemaker or atropine). A HR of 48 is expected in heart block; BP 110/68 is
adequate; occasional PVCs are monitored but not the priority over symptomatic
bradycardia.
2. A client with chronic kidney disease (CKD) has a potassium level of 6.8 mEq/L.
Which intervention should the nurse implement first?
A. Administer IV furosemide
B. Obtain a 12-lead electrocardiogram (ECG)
C. Administer oral sodium polystyrene sulfonate (Kayexalate)
D. Restrict dietary potassium
,Correct Answer: B
Rationale: A potassium of 6.8 is critically high and can cause fatal cardiac
dysrhythmias (peaked T-waves, widened QRS, ventricular fibrillation). The priority
is to assess the cardiac status immediately with an ECG. Furosemide, Kayexalate,
and dietary restrictions are important but are secondary to immediate cardiac
monitoring.
3. A client is receiving a blood transfusion of packed red blood cells. Fifteen
minutes after the start, the client reports low back pain, chills, and feels "hot."
What is the nurse's priority action?
A. Slow the infusion rate and monitor closely
B. Stop the transfusion and infuse normal saline
C. Administer acetaminophen (Tylenol) for chills
D. Notify the healthcare provider
Correct Answer: B
Rationale: Low back pain, chills, and fever are classic signs of an acute hemolytic
transfusion reaction (ABO incompatibility). The priority is to STOP the transfusion
immediately to prevent further hemolysis, but keep the IV line open with normal
saline (not dextrose) to maintain venous access. The provider is notified AFTER
stopping the transfusion.
4. 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
waterproof dressing is not sufficient. All other statements are correct: ties should
be snug (two fingers' width), humidification is needed, and emergency supplies
must be kept at home.
5. The nurse is caring for a client with a chest tube to a water-seal drainage
system. The nurse notes continuous bubbling in the water-seal chamber. What is
the priority nursing action?
A. Clamp the chest tube immediately
B. Assess the system for an air leak
C. Increase the suction pressure
D. Document the finding as normal
Correct Answer: B
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak
somewhere in the system (client-tube connection, or drainage unit). The nurse
must systematically check all connections and the insertion site to locate the leak.
Clamping the tube is contraindicated (can cause tension pneumothorax).
Intermittent bubbling is normal; continuous is not.
6. A client with a history of atrial fibrillation is prescribed warfarin (Coumadin).
The client's INR is 4.5. Which action should the nurse take?
A. Administer the next scheduled dose of warfarin
B. Hold the warfarin and notify the healthcare provider
C. Administer vitamin K orally
D. Increase the warfarin dose
, Correct Answer: B
Rationale: The therapeutic INR for atrial fibrillation is 2.0-3.0. An INR of 4.5 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 head injury has an intracranial pressure (ICP) of 22 mmHg.
Which nursing intervention is most appropriate?
A. Place the client in a flat, supine position
B. Elevate the head of the bed to 30 degrees and maintain midline neck position
C. Cluster all nursing activities together to minimize stimulation
D. Encourage the client to cough and deep breathe
Correct Answer: B
Rationale: Normal ICP is 5-15 mmHg; 22 is elevated. Elevating the HOB to 30
degrees and keeping the neck in a neutral midline position promotes venous
drainage from the brain, thereby reducing ICP. Flat positioning (A) increases ICP.
Clustering care (C) INCREASES ICP (stimuli should be spaced out). Coughing (D)
increases ICP via Valsalva.
8. A client with major depressive disorder is started on phenelzine (Nardil), an
MAOI. Which food should the nurse instruct the client to avoid?
A. Fresh mozzarella cheese
B. Aged cheddar cheese
C. Roasted chicken
D. Apples
Correct Answer: B
Rationale: MAOIs interact with foods high in tyramine, leading to a hypertensive
Predictor Questions and Rationales
1. The nurse is caring for a client with a complete heart block (third-degree AV
block). Which finding requires immediate intervention?
A. Heart rate of 48 beats/min
B. Blood pressure of 110/68 mmHg
C. Client reports feeling dizzy and lightheaded
D. Occasional premature ventricular contractions (PVCs)
Correct Answer: C
Rationale: Complete heart block can cause severe bradycardia and decreased
cardiac output. Dizziness and lightheadedness indicate cerebral hypoperfusion and
may precede syncope or cardiac arrest. This requires immediate intervention
(pacemaker or atropine). A HR of 48 is expected in heart block; BP 110/68 is
adequate; occasional PVCs are monitored but not the priority over symptomatic
bradycardia.
2. A client with chronic kidney disease (CKD) has a potassium level of 6.8 mEq/L.
Which intervention should the nurse implement first?
A. Administer IV furosemide
B. Obtain a 12-lead electrocardiogram (ECG)
C. Administer oral sodium polystyrene sulfonate (Kayexalate)
D. Restrict dietary potassium
,Correct Answer: B
Rationale: A potassium of 6.8 is critically high and can cause fatal cardiac
dysrhythmias (peaked T-waves, widened QRS, ventricular fibrillation). The priority
is to assess the cardiac status immediately with an ECG. Furosemide, Kayexalate,
and dietary restrictions are important but are secondary to immediate cardiac
monitoring.
3. A client is receiving a blood transfusion of packed red blood cells. Fifteen
minutes after the start, the client reports low back pain, chills, and feels "hot."
What is the nurse's priority action?
A. Slow the infusion rate and monitor closely
B. Stop the transfusion and infuse normal saline
C. Administer acetaminophen (Tylenol) for chills
D. Notify the healthcare provider
Correct Answer: B
Rationale: Low back pain, chills, and fever are classic signs of an acute hemolytic
transfusion reaction (ABO incompatibility). The priority is to STOP the transfusion
immediately to prevent further hemolysis, but keep the IV line open with normal
saline (not dextrose) to maintain venous access. The provider is notified AFTER
stopping the transfusion.
4. 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
waterproof dressing is not sufficient. All other statements are correct: ties should
be snug (two fingers' width), humidification is needed, and emergency supplies
must be kept at home.
5. The nurse is caring for a client with a chest tube to a water-seal drainage
system. The nurse notes continuous bubbling in the water-seal chamber. What is
the priority nursing action?
A. Clamp the chest tube immediately
B. Assess the system for an air leak
C. Increase the suction pressure
D. Document the finding as normal
Correct Answer: B
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak
somewhere in the system (client-tube connection, or drainage unit). The nurse
must systematically check all connections and the insertion site to locate the leak.
Clamping the tube is contraindicated (can cause tension pneumothorax).
Intermittent bubbling is normal; continuous is not.
6. A client with a history of atrial fibrillation is prescribed warfarin (Coumadin).
The client's INR is 4.5. Which action should the nurse take?
A. Administer the next scheduled dose of warfarin
B. Hold the warfarin and notify the healthcare provider
C. Administer vitamin K orally
D. Increase the warfarin dose
, Correct Answer: B
Rationale: The therapeutic INR for atrial fibrillation is 2.0-3.0. An INR of 4.5 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 head injury has an intracranial pressure (ICP) of 22 mmHg.
Which nursing intervention is most appropriate?
A. Place the client in a flat, supine position
B. Elevate the head of the bed to 30 degrees and maintain midline neck position
C. Cluster all nursing activities together to minimize stimulation
D. Encourage the client to cough and deep breathe
Correct Answer: B
Rationale: Normal ICP is 5-15 mmHg; 22 is elevated. Elevating the HOB to 30
degrees and keeping the neck in a neutral midline position promotes venous
drainage from the brain, thereby reducing ICP. Flat positioning (A) increases ICP.
Clustering care (C) INCREASES ICP (stimuli should be spaced out). Coughing (D)
increases ICP via Valsalva.
8. A client with major depressive disorder is started on phenelzine (Nardil), an
MAOI. Which food should the nurse instruct the client to avoid?
A. Fresh mozzarella cheese
B. Aged cheddar cheese
C. Roasted chicken
D. Apples
Correct Answer: B
Rationale: MAOIs interact with foods high in tyramine, leading to a hypertensive
