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UPDATED KAPLAN READINESS EXAM WITH 160+
QUESTIONS AND CORRECT ANSWERS/ NCLEX
READINESS REAL EXAM QUESTIONS WITH
ANSWERS (BRAND NEW!!)
Select the 3 priority actions the nurse considers at this time. - ANSWER ✔✔- Notify the physician of abnormal labs and diagnostic results. Place the client on a continuous cardiac monitor. Obtain a list of the client's home medications. The client's adult child arrives at the hospital and provides a list of the client's home medications. The adult child speaks with the orthopedic surgeon. The client is scheduled for an open reduction and internal fixation of the left hip the following morning. The nurse plans the client's care. Complete the following sentences by choosing from the list of options. - ANSWER ✔✔- The nurse ensures the client continues to take levothyroxine as scheduled It is a priority for the nurse to determine if the client has an advance directive. The nurse also plans to request a case manager to speak with the client's child. Following surgery and recovery in the post anesthesia care unit, the client is transported back to the orthopedic unit. For each body system below, click to specify the potential nursing intervention that is appropriate for the care of the client upon return to the orthopedic unit. Each body system supports 1 potential nursing intervention. - ANSWER ✔✔- Body System-Potential Nursing Interventions Cardiovascular-Assess the client's apical rate and cardiac rhythm
Pulmonary = Monitor breath sounds and pulse oximetry every hour. Neurologic = Reorient the client frequently NGN - ANSWER ✔✔- A pregnant client receives an epidural anesthetic. After administration of the epidural the client's blood pressure changes from 120/84 to 94/50. Which action by the nurse is most appropriate? - ANSWER ✔✔- Place the client on the left side with legs flexed. The nurse teaches reality orientation to the spouse of a client with diagnoses of Alzheimer disease and moderate hearing loss. Which statement, if made by the client's spouse, indicates understanding this technique? - ANSWER ✔✔- "I should place a calendar and clock in an obvious place." The nurse cares for a client with a history of type 1 diabetes mellitus who has just returned to the surgical acute-care unit after a right below-knee amputation. The client's capillary blood glucose is 480 mg/dL (26.6 mmol/L). The postoperative orders indicate 6 units of regular insulin subcutaneously should be administered. Which is the first action the nurse should take? - ANSWER ✔✔- Administer the 6 units of regular insulin subcutaneously. The nurse cares for the client after a lumbar laminectomy. Which action by the nurse is most important? - ANSWER ✔✔- Place a pillow between the client's legs and then turn the client. The home care nurse cares for the client who is diagnosed with hypertension and mild depression. The client's adult child states that the client has been falling
most appropriate? - ANSWER ✔✔- "I will need to call the nurse manager about your request." The nurse teaches a client with a spinal cord injury how to perform self- catheterization at home. Which statement, if made by the client, indicates that teaching has been successful? The nurse teaches a client with a spinal cord injury how to perform self-catheterization at home. Which statement, if made by the client, indicates that teaching has been successful? 1. - ANSWER ✔✔- "I will not reuse a single-use catheter when catheterizing myself." A client admitted to the hospital has chest pain when taking deep breaths and peripheral edema. The health care provider (HCP) prescribed "digoxin 0.25 mg orally now. Repeat digoxin 0.25 mg orally in 12 hours." Which action, if taken by the nurse, is best? - ANSWER ✔✔- Review the client's serum digoxin level. The outcome is desired. The nurse reviews the client's serum digoxin level prior to administering the prescribed dose. A level greater than 2 ng/mL indicates toxicity; therefore, it would necessitate holding the prescribed medication and notifying the HCP. The nurse cares for the client diagnosed with Parkinson disease (PD). The nurse notes that the client is ambulating with short, accelerating steps. Which action is the most appropriate for the nurse to take? - ANSWER ✔✔- Teach the client to walk with a broad-based gait. The nurse makes a follow-up phone call to the family of an infant receiving treatment for watery diarrhea. The infant has had 7 days of amoxicillin therapy. The nurse knows teaching is successful if the family makes which statement? - ANSWER ✔✔- "We wear a fresh pair of clean gloves with each diaper change."
A client contaminated with an unidentified hazardous material from work arrives by ambulance at the hospital. Which action does the nurse perform first? - ANSWER ✔✔- Determine if decontamination occurred at the site The nurse cares for a client diagnosed with a complete spinal cord injury 12 weeks ago due to compression fractures of the 5th and 6th cervical vertebrae. The client reports a sudden onset of sweating and has a flushed face and chest. Which action should the nurse take first? - ANSWER ✔✔- Place the client in high-Fowler position. NGN The nurse reviews the client's history and physical and obtains the client's vital signs. Which finding does the nurse associate with normal aging? (Select all that apply.) - ANSWER ✔✔- Reports decreased hearing. Scattered scabbing and bruising on hands and forearms.. Wears bifocals. The client's diagnostic studies are complete, and the nurse reviews the client's results and laboratory findings. Drag the choices below to fill in each blank in the following sentence. Each choice will only be used once. - ANSWER ✔✔- The nurse understands the client is at greatest risk to develop pneumonia, rhabdomyolysis, and cardiac dysrhythmias. The nurse cares for clients in the antepartum clinic. Which client should the nurse see first? - ANSWER ✔✔- A 24-year-old multigravida client at 32 weeks gestation with moderate facial edema. A parent brings a 15-month-old infant to the pediatric clinic for immunizations. The parent tells the nurse that the infant has been diagnosed with cancer and is being treated with chemotherapy. The nurse should question the administration of which immunization? - ANSWER ✔✔- Measles/mumps/rubella (MMR)
of the client? (Select all that apply.) - ANSWER ✔✔- Auscultate for "whooshing" sound over the fistula. Palpate for warmth and tenderness over the area of the fistula. Instruct the client to avoid carrying heavy objects with the left arm. A school-age child is brought to the emergency department following a bicycle fall. An x-ray reveals healed fractures of the ribs. The child's parent states, "My child is careless and is always having accidents." Which response by the nurse is the highest priority? - ANSWER ✔✔- "I will need to perform a thorough head-to- toe assessment and possibly take pictures for documentation." NGN The nurse reviews the client's assessments and vital signs and calls the surgeon. Which intervention does the nurse anticipate the physician will order? (Select all that apply.) - ANSWER ✔✔- Prepare the client to return to surgery. Type and cross match client for 2 units of packed red cells. Increase the IV rate to 100 mL/hr. ✓ (+1pt) A client is prescribed haloperidol 5 mg IM every 4 hours PRN agitation. Which observation requires an immediate intervention by the nurse? - ANSWER ✔✔- Client has tongue protrusion and muscle rigidity. extrapyramidal reactions usually dose- related; controlled by dose-reduction or antiparkinsonian medications (benztropine) Alert and oriented x 4, cooperative, and expressing much concern with symptoms over the last 6-8 weeks. The client reports being very stiff in the mornings and has difficulty moving about after getting out of bed, especially with the left knee. Over the course of the day using a computer at work, the client notices both wrists are sore and seem swollen. "This is all new to me," states the client. Denies any recent or past injuries or illness. The client suspects "arthritis since my father had
it." Lungs clear bilaterally, heart regular. Abdomen soft with active bowel sounds x 4 quadrants. Admits to pneumonia 5 years ago, quit smoking at that time. Wears glasses and instills eye drops for glaucoma. States does have random issues with constipation and often requires a laxative. - ANSWER ✔✔- Potential Condition= Rheumatoid arthritis Action to take = Refer to a dietician. Teach client to pace activities Parameters to monitor = Activities of daily living. Pain level An older adult client is admitted to the hospital with a diagnosis of pneumonia. Upon arrival to the unit, which action should the nurse take first? - ANSWER ✔✔- Assess mental status. The priority for an older adult client is to determine if the pneumonia is creating hypoxia, which often results in altered mental status. Experimental question - ANSWER ✔✔- The nurse teaches the four stages of labor during a prenatal class. Which description by the nurse indicates the third stage of labor?
- "Slow opening of the cervix."
- "Separation and birth of the placenta."
- "The birth of the newborn."
- "The first two hours after birth."
The nurse provides care for a client diagnosed with chronic bronchitis. Which is the best description of expected breath sounds heard during auscultation? - ANSWER ✔✔- Deep, low-pitched rumbling sounds heard during expiration. The spouse of a client at 39 weeks gestation calls the clinic nurse and states, "My spouse's water just broke, and I think the baby is coming now!" Which statement, if made by the nurse, is best? - ANSWER ✔✔- "Look at your spouse's vaginal area and tell me what you see." The nurse cares for an older adult client diagnosed with Alzheimer disease. It is most important for the nurse to take which action? - ANSWER ✔✔- Frequently inform the client of the room and bathroom location. A client is admitted with a diagnosis of acquired immune deficiency syndrome (AIDS). The lab results are hemoglobin 9.3 g/dL (93 g/L), hematocrit 25% (0.25), platelets 50,000/mm3 (50 x 109/L), white cell count 1,500/mm3 (1.5 x 109/L). Which order does the nurse implement first? - ANSWER ✔✔- 4. "Place the client on neutropenic precautions." A 12-year-old boy diagnosed with a fractured right femur is placed in balanced suspension traction with a Thomas splint and Pearson attachment. The nurse is most concerned by which client statement? - ANSWER ✔✔- "I will experience more muscle spasms and pain while my leg is in traction." The health care provider (HCP) orders hydralazine 25 mg IM on call for the client before surgery. The LPN/LVN administers hydroxyzine 25 mg IM to the client. Which is the most appropriate action for the nurse to take? - ANSWER ✔✔- Document "Hydralazine 25 mg ordered; hydroxyzine 25 mg given; HCP notified; blood pressure 130/84; pulse 86; respiration 12."
The nurse performs an assessment of a newborn. The nurse is most concerned by which observation? - ANSWER ✔✔- Stroking the outer sole of the infant's foot upward causes the toes to curl downward. Assessment: outcome not expected and is a problem; Babinski reflex; in newborn, should see dorsiflexion of big toe During a paracentesis, 1500 mL of fluid is removed from the client. Which action should the nurse take immediately following the procedure? - ANSWER ✔✔- Check the client's blood pressure. Assessment: outcome priority; complication of procedure is hypotension (hypovolemic shock due to fluid shift); also check for tachycardia, oliguria, pallor The spouse of an older adult client who is incontinent asks the nurse whether the client will have to wear adult briefs. Which response is most appropriate? - ANSWER ✔✔- "Let's discuss your specific concerns about your spouse. The nurse instructs a client about taking 100 mg losartan and 25 mg hydrochlorothiazide tablets once daily. Which statement requires an intervention by the nurse? - ANSWER ✔✔- "I understand that I may develop a dry cough while taking this medication." Hydrochlorothiazide is a diuretic. The duration effect is 6 to 12 hours, and the medication should be taken in the morning to prevent nocturia. Losartan is an angiotensin receptor blocker (ARB) that may cause angioedema. Any symptoms of angioedema should be reported to the health care provider immediately. Both medications may be taken with or without food.
Start the HD treatment. Parameters to Monitor = Lung sounds Weight The nurse triages clients in the emergency department. Which client does the nurse see first? - ANSWER ✔✔- The client with burns on the face, chest, and hands. BP 120/80 mm Hg, P 100, R 24, T 98.8°F (37°C). Experimental Qs The nurse provides care for an older adult client on an impatient psychiatric unit who is admitted for schizophrenia. Nurse's Notes 0800: Over an hour of continuous observation, the client demonstrated an unusual lack of movement or speech. The client maintained a fixed posture, sitting in the corner of the room, facing the wall with arms pressed against the wall. No verbal communication was initiated by the client. When addressed, the client showed little or no reaction, not making eye contact with anyone in the room. Despite having a meal served, the client did not move to eat or drink. The nurse reviews the client's assessment data to prepare the client's plan of care. • - ANSWER ✔✔- Actions to Take Administer lorazepam 2mg IV now. Apply compression stockings to the lower extremities. Use loud communication to stimulate the client. Prepare the client for group therapy. Potential Condition = Catatonia. Depersonalization. Echopraxia. Negativism. Potential Complications to Monitor = For Dehydration. Hyperglycemia.
Seizure. Right-sided weakness. Venous thromboembolism. The nurse discusses an appropriate diet with a client diagnosed with iron- deficiency anemia. Which meal selection indicates to the nurse that teaching is effective? - ANSWER ✔✔- Pork chop, baked potato, and tossed green salad. Experimental Qs The nurse provides palliative care for a client diagnosed with terminal cancer. The client expresses sadness while discussing the terminal condition. Which approach by the nurse is best to use when responding to the client? - ANSWER ✔✔- 1. Ask the client to talk about the family.
- Encourage the client to express feelings.
- Offer resources that can be used for symptom management.
- Suggest potential ways to manage stress. A client calls the healthcare provider's office reporting a rash, intermittent fever, headache, fatigue, muscle pain, and stiff neck. It is most important for the nurse to ask which question? - ANSWER ✔✔- "Have you noticed any tick bites recently?" symptoms of Lyme disease; causes localized and systemic symptoms The client tells the clinic nurse that the client is thinking about using nicotine polacrilex. Which question is most important for the nurse to ask? - ANSWER ✔✔- Have you ever had chest pain?"
The nurse instructs a client about furosemide, spironolactone, and a low-sodium diet. Which statement by the client indicates the need for further instruction? - ANSWER ✔✔- "Now that I have to limit my sodium intake, I plan to use salt substitutes." Salt substitutes contain potassium, and spironolactone is a potassium-sparing diuretic. The client is at risk for hyperkalemia. The nurse reviews room assignments for clients just admitted to the unit. The nurse questions which assignment? - ANSWER ✔✔- An adolescent diagnosed with cellulitis of the right leg in a semi-private room with a client diagnosed with type 1 diabetes. The nurse knows it is inappropriate to put a client with cellulitis and a client with type 1 diabetes together because of the risk for infection. The client takes 200 mg carbamazepine orally twice daily. The client asks the nurse about future pregnancies. Which statement by the nurse is most appropriate? - ANSWER ✔✔- "You should contact your health care provider and discuss your concerns about pregnancy." Carbamazepine may be teratogenic. The health care provider should discuss risks and benefits with the client. The health care provider prescribes furosemide and spironolactone. Before administering the furosemide and spironolactone, the nurse determines that the client's potassium level is 3.2 mEq/L (3.2 mmol/L). Which is the most important action for the nurse to take? - ANSWER ✔✔- Administer only the spironolactone.
A client comes to the outpatient clinic to receive the influenza (flu) vaccine. Which is the best question the nurse would ask the client? - ANSWER ✔✔- "Do you have any food allergies?" The nurse cares for clients in the pediatric clinic. Which client should the nurse see first? - ANSWER ✔✔- An 8-month-old infant who had 6 watery stools in the past 8 hours. A client had a gastric bypass procedure 4 hours ago. Vital signs are BP 92/68 mm Hg, P 112/min, and RR 22/min. Which prescription does the nurse question? - ANSWER ✔✔- Epinephrine 1 mg IV push. The nurse identifies the client with which diagnosis as at risk of developing metabolic acidosis? (Select all that apply.) - ANSWER ✔✔- Type 1 diabetes. Salicylate toxicity. Acute kidney failure. Severe diarrhea. A 25-year-old multigravida is 22 weeks gestation. The client calls the clinic and informs the nurse, "I was exposed to rubella 2 days ago". Which statement, if made by the nurse, is most appropriate? - ANSWER ✔✔- "Come in this afternoon for your regularly scheduled appointment." The mental health nurse is working with the police response unit to care for an adult client. Report Emergency Medical Services (EMS) Dispatch: Emergency response to the governor's residence. A disheveled adult wearing torn red sweat pants and a dirty
by the nurse is best? - ANSWER ✔✔- "This is not the way to give your message. Come with me and we will get you some help." The client remains agitated and insisting the governor must hear the message. When planning the client's care, which 4 methods of verbal or non-verbal communication does the nurse consider? - ANSWER ✔✔- Stand with relaxed posture a few feet away, arms loose. Ask open-ended questions about the client's life and family. Let the client have time to speak and listen carefully. Tell the client, "I know this must be frustrating for you." Complete the following sentences by choosing from the list of options. - ANSWER ✔✔- The nurse helps the client relax and feel safe. It is a priority for the nurse to have the responding officers approach the client slowly and calmly
- ANSWER ✔✔- Assessment Finding Client is clean, hair brushed, and wearing fresh clothes. = Improved Client states, "I am taking fluphenazine every day and meeting with my counselor weekly." = Improved Client apologizes for behavior at the governor's residence. = Improved Client slaps self and mutters, "Stop it. They'll see you." = No change To locate the point of maximal impulse (PMI) of a client's heart, the nurse's hand (fingertips) should be placed over which location? - ANSWER ✔✔- The forward thrust of the left ventricle during systole produces normal pulsation on the chest wall. The PMI should be felt at the 5th intercostal space.
The client diagnosed with a stroke develops dysphagia. Before allowing the client to eat, which action should the nurse take first? - ANSWER ✔✔- Check client's gag reflex. The nurse prepares to administer the initial dose of oral enalapril 20 mg in the morning. Which medication should the nurse question giving to the client? - ANSWER ✔✔- 40 mg oral furosemide in the morning. may promote significant diuresis; first dose of ACE inhibitors increases risk of "first dose" phenomenon due to vasodilation; combination of vasodilation and diuresis increases risk of orthostatic hypotension After the unexpected death of a client, the nurse observes the spouse standing with the adult children. Which statement by the nurse is most appropriate? - ANSWER ✔✔- "This must be a difficult time for you; I will stay with you." The nurse teaches a client about how to care for an ileostomy. Which comment, if made by the client to the nurse, indicates further teaching is needed? - ANSWER ✔✔- "I should take polyethylene glycol with a large glass of water." An adolescent is admitted to the hospital with a diagnosis of bacterial meningitis. Which action, if observed by the nurse, would require an intervention? - ANSWER ✔✔- The unlicensed assistive personnel (UAP) leaves the client's room with the face mask hanging from the neck. The nursing team consists of one RN, one LPN/LVN and two unlicensed assistive personnel (UAP). Which assignment is most appropriate for the LPN/LVN? - ANSWER ✔✔- An older adult client diagnosed with a thrombotic cerebrovascular accident 5 days ago.
