KAPLAN RN FUNDAMENTALS C
FORMATTED QUESTIONS WITH
CORRECT DETAILED ANSWERS AND
RATIONALES LATEST EXAM TESTED
AND APPROVED!!
1. A nurse is calculating intake for a client from 0700 to 1500. The client drinks 8 oz
of water, 6 oz of coffee, and 4 oz of juice. The client also receives 200 mL of IV
fluids. What is the total intake in mL? (Enter numeric value only.)
A. 540 mL
B. 540 mL (8 oz = 240 mL, 6 oz = 180 mL, 4 oz = 120 mL; 240+180+120 = 540 mL oral +
200 mL IV = 740 mL)
C. 740 mL
D. 840 mL
• Answer: C. 740 mL
• *Rationale: Convert ounces to mL (1 oz = 30 mL). 8 oz water = 240 mL; 6 oz coffee =
180 mL; 4 oz juice = 120 mL. Total oral = 540 mL. Add 200 mL IV = 740 mL total intake.*
2. A nurse is providing postmortem care. Which of the following actions is appropriate?
A. Place the client in a supine position with arms crossed.
B. Remove all dentures and place them in a labeled cup.
C. Place a rolled towel under the client's head to maintain alignment.
D. Close the client's eyes by gently pressing on the eyelids.
,• Answer: D. Close the client's eyes by gently pressing on the eyelids.
• Rationale: Closing the eyes is a standard respectful practice in postmortem care. Dentures should
be left in place to maintain facial shape unless policy states otherwise. The head is often slightly
elevated to prevent discoloration.
3. A nurse is reinforcing teaching with a client about using a patient-controlled analgesia
(PCA) pump. Which statement by the client indicates understanding?
A. "I will ask my family member to press the button if I am sleeping."
B. "I should only press the button when the pain becomes severe."
C. "The pump is programmed to prevent me from receiving too much medication."
D. "I will need to be monitored for breathing problems only for the first hour."
• Answer: C. "The pump is programmed to prevent me from receiving too much medication."
• Rationale: PCA pumps have a lockout mechanism to prevent overdosage. Only the client should
press the button. Pain should be managed proactively, not only at severe levels.
4. A nurse is caring for a client who is postoperative and has a Jackson-Pratt (JP) drain.
Which of the following findings indicates proper drain function? A. The drain is fully
expanded and firm.
B. There is no drainage in the bulb.
C. The bulb is compressed and has negative pressure.
D. The drain is disconnected from the suction device.
• Answer: C. The bulb is compressed and has negative pressure.
• Rationale: A JP drain works by negative pressure. The bulb should be compressed (flattened) to
create suction that pulls fluid into the drain.
5. A nurse is preparing to administer a cleansing enema to a client. The client asks, "Why
do I need this enema?" Which of the following is an appropriate response?
A. "It will help relieve your constipation."
, B. "It's to clean out your bowels before your X-ray."
C. "Your provider ordered it, so it's necessary."
D. "It will make you more comfortable."
• Answer: B. "It's to clean out your bowels before your X-ray."
• Rationale: This provides a clear, specific, and truthful reason for the enema (e.g., for diagnostic
procedures, constipation relief, or bowel prep). Vague or authoritarian responses do not promote
client understanding.
6. A nurse is assessing a client's peripheral IV site. Which of the following findings
indicates phlebitis?
A. Coolness and pallor around the site
B. Redness, warmth, and a palpable cord
C. Edema that resolves with elevation
D. Infiltration of fluid into the tissue
• Answer: B. Redness, warmth, and a palpable cord.
• Rationale: Phlebitis is inflammation of the vein, presenting as redness, warmth, tenderness, and a
palpable venous cord. Infiltration presents with edema, coolness, and pallor.
7. A nurse is caring for a client who has a new tracheostomy. Which of the following
actions should the nurse take first when performing tracheostomy care? A. Remove the
inner cannula.
B. Don sterile gloves.
C. Suction the tracheostomy tube.
D. Perform hand hygiene.
• Answer: D. Perform hand hygiene.
, • Rationale: Hand hygiene is the first step in any aseptic procedure to reduce the transmission of
microorganisms. All other steps follow after hand hygiene.
8. A nurse is repositioning a client who is in the supine position to a lateral position.
Which of the following actions should the nurse take to prevent shearing force?
A. Slide the client across the sheet.
B. Use a draw sheet to lift the client.
C. Place the bed in the lowest position.
D. Raise the head of the bed to 90 degrees.
• Answer: B. Use a draw sheet to lift the client.
• Rationale: Lifting the client with a draw sheet reduces friction and shearing (rubbing of skin
against a surface). Sliding increases shearing risk.
9. A nurse is assessing a client's breath sounds. Which of the following sounds is
considered normal and expected over the peripheral lung fields?
A. Bronchial
B. Vesicular
C. Bronchovesicular
D. Crackles
• Answer: B. Vesicular.
• Rationale: Vesicular breath sounds are soft, low-pitched sounds heard over most of the peripheral
lung fields. Bronchial sounds are heard over the trachea; bronchovesicular over main bronchi.
10. A nurse is caring for a client who is receiving a blood transfusion. The client reports
chills and low back pain. What should the nurse do first?
A. Slow the infusion rate.
B. Administer acetaminophen as prescribed.
FORMATTED QUESTIONS WITH
CORRECT DETAILED ANSWERS AND
RATIONALES LATEST EXAM TESTED
AND APPROVED!!
1. A nurse is calculating intake for a client from 0700 to 1500. The client drinks 8 oz
of water, 6 oz of coffee, and 4 oz of juice. The client also receives 200 mL of IV
fluids. What is the total intake in mL? (Enter numeric value only.)
A. 540 mL
B. 540 mL (8 oz = 240 mL, 6 oz = 180 mL, 4 oz = 120 mL; 240+180+120 = 540 mL oral +
200 mL IV = 740 mL)
C. 740 mL
D. 840 mL
• Answer: C. 740 mL
• *Rationale: Convert ounces to mL (1 oz = 30 mL). 8 oz water = 240 mL; 6 oz coffee =
180 mL; 4 oz juice = 120 mL. Total oral = 540 mL. Add 200 mL IV = 740 mL total intake.*
2. A nurse is providing postmortem care. Which of the following actions is appropriate?
A. Place the client in a supine position with arms crossed.
B. Remove all dentures and place them in a labeled cup.
C. Place a rolled towel under the client's head to maintain alignment.
D. Close the client's eyes by gently pressing on the eyelids.
,• Answer: D. Close the client's eyes by gently pressing on the eyelids.
• Rationale: Closing the eyes is a standard respectful practice in postmortem care. Dentures should
be left in place to maintain facial shape unless policy states otherwise. The head is often slightly
elevated to prevent discoloration.
3. A nurse is reinforcing teaching with a client about using a patient-controlled analgesia
(PCA) pump. Which statement by the client indicates understanding?
A. "I will ask my family member to press the button if I am sleeping."
B. "I should only press the button when the pain becomes severe."
C. "The pump is programmed to prevent me from receiving too much medication."
D. "I will need to be monitored for breathing problems only for the first hour."
• Answer: C. "The pump is programmed to prevent me from receiving too much medication."
• Rationale: PCA pumps have a lockout mechanism to prevent overdosage. Only the client should
press the button. Pain should be managed proactively, not only at severe levels.
4. A nurse is caring for a client who is postoperative and has a Jackson-Pratt (JP) drain.
Which of the following findings indicates proper drain function? A. The drain is fully
expanded and firm.
B. There is no drainage in the bulb.
C. The bulb is compressed and has negative pressure.
D. The drain is disconnected from the suction device.
• Answer: C. The bulb is compressed and has negative pressure.
• Rationale: A JP drain works by negative pressure. The bulb should be compressed (flattened) to
create suction that pulls fluid into the drain.
5. A nurse is preparing to administer a cleansing enema to a client. The client asks, "Why
do I need this enema?" Which of the following is an appropriate response?
A. "It will help relieve your constipation."
, B. "It's to clean out your bowels before your X-ray."
C. "Your provider ordered it, so it's necessary."
D. "It will make you more comfortable."
• Answer: B. "It's to clean out your bowels before your X-ray."
• Rationale: This provides a clear, specific, and truthful reason for the enema (e.g., for diagnostic
procedures, constipation relief, or bowel prep). Vague or authoritarian responses do not promote
client understanding.
6. A nurse is assessing a client's peripheral IV site. Which of the following findings
indicates phlebitis?
A. Coolness and pallor around the site
B. Redness, warmth, and a palpable cord
C. Edema that resolves with elevation
D. Infiltration of fluid into the tissue
• Answer: B. Redness, warmth, and a palpable cord.
• Rationale: Phlebitis is inflammation of the vein, presenting as redness, warmth, tenderness, and a
palpable venous cord. Infiltration presents with edema, coolness, and pallor.
7. A nurse is caring for a client who has a new tracheostomy. Which of the following
actions should the nurse take first when performing tracheostomy care? A. Remove the
inner cannula.
B. Don sterile gloves.
C. Suction the tracheostomy tube.
D. Perform hand hygiene.
• Answer: D. Perform hand hygiene.
, • Rationale: Hand hygiene is the first step in any aseptic procedure to reduce the transmission of
microorganisms. All other steps follow after hand hygiene.
8. A nurse is repositioning a client who is in the supine position to a lateral position.
Which of the following actions should the nurse take to prevent shearing force?
A. Slide the client across the sheet.
B. Use a draw sheet to lift the client.
C. Place the bed in the lowest position.
D. Raise the head of the bed to 90 degrees.
• Answer: B. Use a draw sheet to lift the client.
• Rationale: Lifting the client with a draw sheet reduces friction and shearing (rubbing of skin
against a surface). Sliding increases shearing risk.
9. A nurse is assessing a client's breath sounds. Which of the following sounds is
considered normal and expected over the peripheral lung fields?
A. Bronchial
B. Vesicular
C. Bronchovesicular
D. Crackles
• Answer: B. Vesicular.
• Rationale: Vesicular breath sounds are soft, low-pitched sounds heard over most of the peripheral
lung fields. Bronchial sounds are heard over the trachea; bronchovesicular over main bronchi.
10. A nurse is caring for a client who is receiving a blood transfusion. The client reports
chills and low back pain. What should the nurse do first?
A. Slow the infusion rate.
B. Administer acetaminophen as prescribed.
