KAPLAN NCLEX FINAL EXAM REVIEW QUESTIONS AND ANSWERS WITH RATIONALES|WELL
STRUCTURED|100 % PASS 2025
QUESTIONS ANSWERS &RATIONALES
(1) may be ordered to determine the
presence of major depression
The nurse cares for a client who presents
(2) may be ordered to check for an en-
with confusion, mood lability, impaired
docrine cause for the symptoms before
communication, and lethargy. The nurse
the diagnosis of dementia is made
should question which of the following
orders?
(3) may be ordered to see if the client's
1. Dexamethasone suppression test. symptoms are caused by excessive use
2. Thyroid studies. of medications or alcohol
3. Drug toxicology screen.
(4) correct—test is used with a client who
4. Trendelenburg test.
may have varicose veins, no relationship
to the symptoms described in this situa-
tion
A client has a total laryngectomy with
a permanent tracheostomy. The nurse
plans nutritional intake for the next 3
days.Which of the following is necessary
(1) correct—tube feedings frequently
for the nurse to consider regarding the
started as the initial nutritional intake;
client's nutrition?
prevents trauma to suture area
1. To facilitate healing of the surgical
(2) although client has permanent tra-
area, a nasogastric tube may be utilized
cheotomy, will be able to eat normally
and tube feedings may be implemented.
after area has healed
2. The client will be unable to maintain
any oral intake as long as the tracheoto-
(3) nutritional intake will begin when bow-
my is in place.
el sounds return and client can tolerate
3. Nutritional and/or gastric feedings
intake
will not be attempted for approximately
3 weeks to decrease the incidence of
(4) client is not dependent on ventilator
aspiration.
4. Because the client is dependent on
the ventilator, nutritional intake will be
delayed.
(1) indicates increased intracranial pres-
sure
, (2) correct—Glasgow coma scale score
For a client with a neurologic disorder,
best evaluates changes in a client's
which of the following nursing assess-
level of consciousness by evaluating
ments is MOST helpful in determining
eye-opening, motor, and verbal respons-
subtle changes in the client's level of
es
consciousness?
1. Client posturing. (3) more appropriate for the psychiatric
2. Glasgow coma scale. client
3. Client thinking pattern.
(4) more appropriate for the psychiatric
4. Occurrence of hallucinations.
client
The nurse conducts a physical examina-
tion of a client suspected to have bulimia.
Which of the following observations by
the nurse MOST likely indicates bulimia? (1) common with anorexia
1. The client has edema of the lower (2) seen with anorexia
extremities.
2. Physical exam of the client reveals the (3) correct—due to frequent vomiting
presence of lanugo.
3. The client has ulcerated mucous (4) bulimics are normal in appearance
membranes of the mouth.
4. The client has dry, yellowish color of
the skin.
(1) not a critical assessment at this time
The nurse prepares a dopamine (In-
tropin) infusion on a client. Before begin- (2) contains correct information, but is
ning the infusion the nurse should take not a priority
which of the following actions?
(3) correct—if extravasation occurs,
1. Evaluate the urine output. there is sloughing of the surrounding skin
2. Obtain the client's weight. and tissue; patent IV line is essential to
3. Determine the patency of the IV line. prevent serious side effects
4. Measure pulmonary artery pressures.
(4) not a critical assessment at this time
The nurse assists a nursing assistant in
(1) correct—contaminated gloves should
providing a bed bath to a comatose pa-
be removed before answering the phone
tient with incontinence. The nurse should
,intervene if which of the following actions
is noted?
(2) correct way to roll a patient to main-
1. The nursing assistant answers the tain proper alignment
phone while wearing gloves.
2. The nursing assistant log rolls the (3) appropriate to use incontinence pad
patient to provide back care. for this patient
3. The nursing assistant places an in-
continent pad under the patient. (4) appropriate position to prevent aspi-
4. The nursing assistant positions the ration and protect the airway
patient on the left side, head elevated.
The nurse instructs a client who is re-
ceiving imipramine (Tofranil). It is MOST (1) correct—possible side effects of
important for the nurse to instruct the Tofranil, a tricyclic antidepressant med-
client to immediately report which of the ication, which can be resolved by altering
following? the dosage or changing the medication
1. Sore throat, fever, increased fatigue, (2) describes side effects of antidepres-
vomiting, diarrhea. sants, which client can learn to manage
2. Dry mouth, nasal stuffiness, weight at home without changing the medication
gain.
3. Rapid heartbeat, frequent headaches, (3) not side effects of Tofranil
yellowing of eyes or skin.
4. Weakness, staggering gait, tremor, (4) not side effects of Tofranil
feeling of drunkenness.
The nurse receives report from the previ- (1) although the patient requires a high
ous shift. Which of the following patients level of nursing care, no indication that
should the nurse see FIRST? the patient is unstable
1. A patient post coronary artery bypass (2) patient requires preoperative assess-
graft (CABG) having the atrioventricular ment and teaching, no indication that the
(AV) wires removed later in the day. patient is unstable
2. A patient with type 1 diabetes sched-
uled for a cardiac catheterization later (3) correct —epidural used for pain re-
today. lief, monitor for urinary incontinence, hy-
3. A patient 1 day postoperative with an potension, respiratory depression, and
epidural catheter in place. nausea and vomiting
4. A patient diagnosed with cardiomy-
, opathy being evaluated for a heart trans- (4) requires monitoring but patient with
plant. epidural takes priority
A child has a closed transverse fracture
(1) correct—assess neurovascular sta-
of the right ulna. Which of the following
tus, check pain, pallor, paralysis, pares-
actions, if performed by the nurse before
thesia, pulselessness
the application of a cast, is MOST impor-
tant?
(2) assessment; temperature indicates
decreased circulation but is subjective
1. Check the radial pulses bilaterally and
and not most important
compare.
2. Evaluate the skin temperature and
(3) assessment; upper (not lower) ex-
tissue turgor in the area.
tremity fracture
3. Assess sensation of each foot while
the child closes her eyes.
(4) implementation; should not be done
4. Apply baby powder to decrease skin
because it would increase skin irritation
irritation under the cast.
The nurse cares for a multipara client
who delivered a female infant 1 hour (1) encourage the client to void before
ago. The nurse observes that the client's catheterizing
breasts are soft; the uterus is boggy to
the right of the midline and 2 cm below (2) correct—boggy uterus deviated to
the umbilicus; moderate lochia rubra. It right indicates full bladder, encourage
is MOST important for the nurse to take client to void
which of the following actions?
(3) will increase uterine tone, but the
1. Perform a straight catheterization. problem is a full bladder
2. Offer the client the bedpan.
3. Put the baby to breast. (4) findings indicate a full bladder
4. Massage the uterine fundus.
The nurse checks for placement of a na-
sogastric (NG) tube prior to initiating a
tube feeding for a client. Which of the (1) mucus may be from lungs
following results indicates to the nurse
that the tube feeding can begin? (2) correct—stomach contents are acidic
1. A small amount of white mucus is (3) not a safe way to check placement
aspirated from the NG tube.
2. The contents aspirated from the NG
STRUCTURED|100 % PASS 2025
QUESTIONS ANSWERS &RATIONALES
(1) may be ordered to determine the
presence of major depression
The nurse cares for a client who presents
(2) may be ordered to check for an en-
with confusion, mood lability, impaired
docrine cause for the symptoms before
communication, and lethargy. The nurse
the diagnosis of dementia is made
should question which of the following
orders?
(3) may be ordered to see if the client's
1. Dexamethasone suppression test. symptoms are caused by excessive use
2. Thyroid studies. of medications or alcohol
3. Drug toxicology screen.
(4) correct—test is used with a client who
4. Trendelenburg test.
may have varicose veins, no relationship
to the symptoms described in this situa-
tion
A client has a total laryngectomy with
a permanent tracheostomy. The nurse
plans nutritional intake for the next 3
days.Which of the following is necessary
(1) correct—tube feedings frequently
for the nurse to consider regarding the
started as the initial nutritional intake;
client's nutrition?
prevents trauma to suture area
1. To facilitate healing of the surgical
(2) although client has permanent tra-
area, a nasogastric tube may be utilized
cheotomy, will be able to eat normally
and tube feedings may be implemented.
after area has healed
2. The client will be unable to maintain
any oral intake as long as the tracheoto-
(3) nutritional intake will begin when bow-
my is in place.
el sounds return and client can tolerate
3. Nutritional and/or gastric feedings
intake
will not be attempted for approximately
3 weeks to decrease the incidence of
(4) client is not dependent on ventilator
aspiration.
4. Because the client is dependent on
the ventilator, nutritional intake will be
delayed.
(1) indicates increased intracranial pres-
sure
, (2) correct—Glasgow coma scale score
For a client with a neurologic disorder,
best evaluates changes in a client's
which of the following nursing assess-
level of consciousness by evaluating
ments is MOST helpful in determining
eye-opening, motor, and verbal respons-
subtle changes in the client's level of
es
consciousness?
1. Client posturing. (3) more appropriate for the psychiatric
2. Glasgow coma scale. client
3. Client thinking pattern.
(4) more appropriate for the psychiatric
4. Occurrence of hallucinations.
client
The nurse conducts a physical examina-
tion of a client suspected to have bulimia.
Which of the following observations by
the nurse MOST likely indicates bulimia? (1) common with anorexia
1. The client has edema of the lower (2) seen with anorexia
extremities.
2. Physical exam of the client reveals the (3) correct—due to frequent vomiting
presence of lanugo.
3. The client has ulcerated mucous (4) bulimics are normal in appearance
membranes of the mouth.
4. The client has dry, yellowish color of
the skin.
(1) not a critical assessment at this time
The nurse prepares a dopamine (In-
tropin) infusion on a client. Before begin- (2) contains correct information, but is
ning the infusion the nurse should take not a priority
which of the following actions?
(3) correct—if extravasation occurs,
1. Evaluate the urine output. there is sloughing of the surrounding skin
2. Obtain the client's weight. and tissue; patent IV line is essential to
3. Determine the patency of the IV line. prevent serious side effects
4. Measure pulmonary artery pressures.
(4) not a critical assessment at this time
The nurse assists a nursing assistant in
(1) correct—contaminated gloves should
providing a bed bath to a comatose pa-
be removed before answering the phone
tient with incontinence. The nurse should
,intervene if which of the following actions
is noted?
(2) correct way to roll a patient to main-
1. The nursing assistant answers the tain proper alignment
phone while wearing gloves.
2. The nursing assistant log rolls the (3) appropriate to use incontinence pad
patient to provide back care. for this patient
3. The nursing assistant places an in-
continent pad under the patient. (4) appropriate position to prevent aspi-
4. The nursing assistant positions the ration and protect the airway
patient on the left side, head elevated.
The nurse instructs a client who is re-
ceiving imipramine (Tofranil). It is MOST (1) correct—possible side effects of
important for the nurse to instruct the Tofranil, a tricyclic antidepressant med-
client to immediately report which of the ication, which can be resolved by altering
following? the dosage or changing the medication
1. Sore throat, fever, increased fatigue, (2) describes side effects of antidepres-
vomiting, diarrhea. sants, which client can learn to manage
2. Dry mouth, nasal stuffiness, weight at home without changing the medication
gain.
3. Rapid heartbeat, frequent headaches, (3) not side effects of Tofranil
yellowing of eyes or skin.
4. Weakness, staggering gait, tremor, (4) not side effects of Tofranil
feeling of drunkenness.
The nurse receives report from the previ- (1) although the patient requires a high
ous shift. Which of the following patients level of nursing care, no indication that
should the nurse see FIRST? the patient is unstable
1. A patient post coronary artery bypass (2) patient requires preoperative assess-
graft (CABG) having the atrioventricular ment and teaching, no indication that the
(AV) wires removed later in the day. patient is unstable
2. A patient with type 1 diabetes sched-
uled for a cardiac catheterization later (3) correct —epidural used for pain re-
today. lief, monitor for urinary incontinence, hy-
3. A patient 1 day postoperative with an potension, respiratory depression, and
epidural catheter in place. nausea and vomiting
4. A patient diagnosed with cardiomy-
, opathy being evaluated for a heart trans- (4) requires monitoring but patient with
plant. epidural takes priority
A child has a closed transverse fracture
(1) correct—assess neurovascular sta-
of the right ulna. Which of the following
tus, check pain, pallor, paralysis, pares-
actions, if performed by the nurse before
thesia, pulselessness
the application of a cast, is MOST impor-
tant?
(2) assessment; temperature indicates
decreased circulation but is subjective
1. Check the radial pulses bilaterally and
and not most important
compare.
2. Evaluate the skin temperature and
(3) assessment; upper (not lower) ex-
tissue turgor in the area.
tremity fracture
3. Assess sensation of each foot while
the child closes her eyes.
(4) implementation; should not be done
4. Apply baby powder to decrease skin
because it would increase skin irritation
irritation under the cast.
The nurse cares for a multipara client
who delivered a female infant 1 hour (1) encourage the client to void before
ago. The nurse observes that the client's catheterizing
breasts are soft; the uterus is boggy to
the right of the midline and 2 cm below (2) correct—boggy uterus deviated to
the umbilicus; moderate lochia rubra. It right indicates full bladder, encourage
is MOST important for the nurse to take client to void
which of the following actions?
(3) will increase uterine tone, but the
1. Perform a straight catheterization. problem is a full bladder
2. Offer the client the bedpan.
3. Put the baby to breast. (4) findings indicate a full bladder
4. Massage the uterine fundus.
The nurse checks for placement of a na-
sogastric (NG) tube prior to initiating a
tube feeding for a client. Which of the (1) mucus may be from lungs
following results indicates to the nurse
that the tube feeding can begin? (2) correct—stomach contents are acidic
1. A small amount of white mucus is (3) not a safe way to check placement
aspirated from the NG tube.
2. The contents aspirated from the NG
