Download "Kaplan NCLEX-RN 2025/2026: 215 Actual Exam Questions & Verified A+ Answers (Latest Editio and more Exams Nursing in PDF only on Docsity!
UPDATED KAPLAN NCLEX RN 215 QUESTIONS AND
CORRECT ANSWERS ALREADY GRADED A+
gravida - ANSWER ✔✔- total number of pregnancies regardless of duration, includes present pregnancy WBC count - ANSWER ✔✔- 4,500-11, Hemoglobin normal range - ANSWER ✔✔- male 13- 18 female 12- 16 RBC count - ANSWER ✔✔- male 4.6 - 6. female 4.2 - 5. Hematocrit range - ANSWER ✔✔- Male 42-52% Female 35-47% PTT purpose - ANSWER ✔✔- monitors effectiveness of heparin therapy; detects coagulation disorders PTT (partial thromboplastin time) - ANSWER ✔✔- lower limit of normal: 20-25 sec upper limit of normal: 32- 39 Platelet count - ANSWER ✔✔- 150,000-400, Prothrombin Time (PT) - ANSWER ✔✔- 9.5-12 seconds
INR (international normalized ratio) - ANSWER ✔✔- 1 sec 2 - 3 sec for afib therapy, DVT, and PE 2.5-3.5 sec for prosthetic heart valve therapy glucose tolerance test (GTT) - ANSWER ✔✔- fasting: 70- 99 1 h: 190 2 h: 140 3 h: 125 total cholesterol - ANSWER ✔✔- 150 - 200 mg/dL LDL - ANSWER ✔✔- <100 mg/dL The lower the better HDL - ANSWER ✔✔- male: 35- 70 female: 35- 85 creatinine (CR) - ANSWER ✔✔- 0 .7-1.4 mg/dL BUN normal range - ANSWER ✔✔- 10 - 20 mg/dL serum albumin - ANSWER ✔✔- 3.5-5.5 g/dL nutritional status
S/s of DI - ANSWER ✔✔- increased urine output, increased plasma osmolarity, urine specific gravity 1.001-1.005, excessive thirst, wt loss, weakness, constipation systemic lupus erythematosus (SLE) - ANSWER ✔✔- chronic inflammatory (multisystem) autoimmune disease involving joints, skin, kidneys, CNS, vascular/lymphatic problems, heart, and lungs SLE interventions - ANSWER ✔✔- Monitor for fever, relieve pain (NSAIDs, acetaminophen), antimalarial meds, protect from UV rays/sunlight, corticosteroids, teach lifestyle changes to prevent infection and decrease risk of CAD hypotonic solution - ANSWER ✔✔- Solute concentration is less than that inside the cell; cell gains water 0.45% isotonic solution - ANSWER ✔✔- same concentration as ECF 0.9% NaCl Lactated Ringers 5% dextrose in water (starts as this) hypertonic solution - ANSWER ✔✔- solute concentration is greater than than inside of cell; cell lose water 3% NaCl 10 - 15% dextrose in water 5% sodium bicarbonate D5NS
What is cystic fibrosis? - ANSWER ✔✔- Inherited respiratory disease Dysfunction in sweat glands, respiratory, and GI system (esp. pancreas) Obstructions r/t flow of thick mucus, sweat, saliva, and digestive secretions Cystic fibrosis treatment - ANSWER ✔✔- postural drainage, chest physiotherapy, expectorants, mucolytic agents, replace pancreatic enzymes, aerosol therapy UTI S/s - ANSWER ✔✔- urinary frequency and urgency burning, pain with voiding possibly visible blood or pus in urine S/s of Pyelonephritis - ANSWER ✔✔- inflammation of kidney chills, fever, malaise, flank pain, CVA tenderness S/s of Cystitis - ANSWER ✔✔- bladder inflammation burning and pain on urination, urinary frequency/urgency, bladder spasms S/s for all hepatitis - ANSWER ✔✔- jaundice, anorexia, RUQ abd pain, clay colored stool, brown urine, pruritus Hepatitis diet - ANSWER ✔✔- low fat, high carb, high protein, no alcohol Color of Lochia (by day) - ANSWER ✔✔- Day 1-3: rubra Day 4-9: serosa Day 10+: alba
S/s of upper respiratory infection - ANSWER ✔✔- rhinorrhea, nasal congestion/discharge, sneezing, teary watery eyes, sore throat S/s of sinusitis - ANSWER ✔✔- facial pressure, stuffy nose, purulent nasal discharge, HA, ear pain, dental pain Tx for Pertussis (whooping cough) - ANSWER ✔✔- Macrolide ABX, do not use cough suppressants or antihistamines, do not use cortisone or bronchodilators S/S of preeclampsia - ANSWER ✔✔- - BP: SBP > 140 and/or 90 diastolic mmHg Occurs 2x (4-6 hours apart)
0.3 g/24 hours Protein/creatinine ratio >0.
- Platelets > 100,
- HA, visual changes, edema Preeclampsia care - ANSWER ✔✔- bed rest in left lateral position, well-balanced diet, daily weights Preeclampsia with severe features - ANSWER ✔✔- - BP: 160/110 or higher
- Proteinuria not necessary
- HA, RU epigastric pain, dizziness, visual changes, anginal pain Severe preeclampsia care - ANSWER ✔✔- bed rest, monitor I/Os, seizure precautions, VS, fetal heart tones, give antihypertensive meds
S/s of eclampsia - ANSWER ✔✔- most serious form of toxemia during pregnancy
- HTN, proteinuria, edema, motor seizures (tonic-clonic)
- occurs between 20-40 weeks of pregnancy eclampsia care - ANSWER ✔✔- bedrest in left lateral position, monitor I/Os, VS, fetal heart tones, seizure precautions, give magnesium sulfate (anticonvulsant), hydralazine (vasodilator), diazepam (sedative, anxiolytic), nifedipine (CCB), well-balanced diet, daily weights Food to avoid in pregnancy - ANSWER ✔✔- raw eggs, shellfish, or fish fish with mercury: swordfish, tuna unpasteurized milk or dairy products, soft cheeses processed/deli meats: bologna, salami, hot dogs S/S of ectopic pregnancy - ANSWER ✔✔- severe, unilateral, lower abd pain pain referred to shoulder abd rigidity bleeding low hct and low HCG levels ectopic pregnancy care - ANSWER ✔✔- assess for hemorrhage and shock provide fluid support prepare for surgery give Rho(D) immune globulin if Rh-negative emotional support Placenta previa - ANSWER ✔✔- placenta grows over cervix S/s: intermittent, painless bleeding during pregnancy
What does amniocentesis show? - ANSWER ✔✔- genetic disorder or lecithin-spingomyelin (L/S) ratio to detect lung maturity (2:1) When is amniocentesis performed? - ANSWER ✔✔- usually 16 weeks or later *bladder should be empty if >20 weeks, may give RhoGam afterwards Nonstress and contraction stress test - ANSWER ✔✔- done after 28 weeks usu. for high-risk pregnancy; assess fetal well-being US records fetal movement and records fetal heart rate Nonstress test (NST) result - ANSWER ✔✔- Reactive = 2+ fetal HR accels of 15 bpm lasting 15 sec over 20 min period with return to baseline Nonreactive = may need CST or immediate delivery Contractions stress test (CST) result - ANSWER ✔✔- Positive = bad; late decels with minimum of 3 contractions; may need immediate delivery Negative = good outcome; no late decels with minimum of 3 contractions Immunizations during pregnancy - ANSWER ✔✔- Safe: flu, Tdap Avoid: live vaccines including MMR, varicella, and herpes zoster (may give post delivery) Responding to fetal distress - ANSWER ✔✔- LIONS: Left side (if no change, trendelenburg or knee chest) IV fluids O2 by mask Notify HCP
Stop labor-inducing meds APGAR - ANSWER ✔✔- HR: absent = 0, <100 = 1, >100 = 2 Respiratory effort (Cry): absent =0, slow/irregular/weak cry = 1, good cry = 2 Muscle tone: flaccid/limp = 0, some flexion of extremities/sluggish = 1, well flexed/actively moving/strong = 2 Reflex response: no response = 0, grimace upon stimulation= 1, vigorous cry = 2 Color: blue/pale = 0, blue/pink = 1, all pink = 2 Scores: 0 - 3 = poor 4 - 6 = fair 7 - 10 = excellent Leading causes of CKD - ANSWER ✔✔- DM and HTN Other: glomerulonephritis, interstitial cystitis, polycystic kidney disease, pyelonephritis, exposure to nephrotoxic meds and chemicals, and obstructive urinary tract disease Normal function of kidneys - ANSWER ✔✔- remove waste (urea and creatinine) filter and remove excess insulin excrete excess K+ regulate NA and H2O Control BP through RAAS Make erythropoietin which stimulates production of RBCs in bone marrow
No QRS complex Chaotic Rhythm **Intubation, rapid D-Fib, Epinephrine, Lidocaine Carbamazepine - ANSWER ✔✔- Anticonvulsant AE: myelosuppression, rash Care: monitor I/Os, CBC, supervise ambulation Teach: take with meals, protect from sun, do not decrease dose or discontinue abruptly phenytoin - ANSWER ✔✔- Anticonvulsant AE: lethargy, GI upset, gingival hypertrophy Care: never mix with other IV meds or dextrose Teach: take with at least 1/2 glass of water or meals; sweat, urine might become red-brown or pink; oral hygiene; alcohol increases serum levels Anticonvulsants - ANSWER ✔✔- clonazepam, DIAZEPAM, fosphenytoin, levetiracetam, PHENYTOIN sodium, primidone, magnesium sulfate, valproic acid, carbamazepine, ethosuximide, gabapentin, lamotrigine, topiramate Anticonvulsants AE - ANSWER ✔✔- CV depression, respiratory depression, agranulocytosis, aplastic anemia Teach: tolerance develops with long term use, don't discontinue abruptly; caution use with MAOIs, increased risks for elderly hyperthyroidism / grave's disease - ANSWER ✔✔- autoimmune; abnormally high secretion of thyroid hormones, increases metabolism S/S of hyperthyroidism (Graves Disease) - ANSWER ✔✔- goiter caused by too much production of T3 and T4and decreased TSH
tachycardia/palpations heat intolerance increased metabolic rate/wt loss insomnia/nervousness exophthalmos (protruding eyes) Erikson stages of development - ANSWER ✔✔- 1. trust vs mistrust (birth-12months)
- autonomy vs shame/doubt (12months-3years)
- initiative vs guilt (3-6years)
- industry vs inferiority (6-12years)
- identity vs role confusion (12-20years)
- intimacy vs isolation (20-40years)
- generativity vs stagnation (40-65years)
- ego integrity vs despair (65+years) Infant reflexes - ANSWER ✔✔- Stepping (up to 4 weeks) Tonic neck (3-4 months) Moro (3-4 months) Babinski (24 months - reverts to adult response) Palmar (3-4 months) Rooting (4-7 months) Plantar (8 months)
*RSV related RSV (respiratory syncytial virus) - ANSWER ✔✔- highly contagious viral respiratory infection, major cause of respiratory illness in young children Tetralogy of Fallot - ANSWER ✔✔- congenital malformation involving four distinct heart defects
- interventricular septal defect
- pulmonic stenosis
- overriding aorta (receives blood from both ventricles)
- right ventricular hypertrophy S/s of tetralogy of fallot - ANSWER ✔✔- *cyanosis - hallmark (blue spells or tet spells) murmur clubbing of fingers delayed physical growth and development squatting NSAID AE - ANSWER ✔✔- Bleeding (esp. GI) Heartburn Nausea Anaphylaxis HA Dizziness Types of NSAIDs - ANSWER ✔✔- aspirin, ibuprofen, naproxen, diclofenac, indomethacin, ketorolac, nabumetone, sulindac, celecoxib
acetaminophen (similar NSAID properties except antiinflammatory) leukopenia precautions - ANSWER ✔✔- meal well done brush and floss after every meal no exposure to dirt (gardening) no exposure to fresh-cut flowers rinse toothbrush w/ bleach solution no alcohol based mouthwash bathe daily w/ antimicrobial soap nothing fresh (veggies, fruit, ground pepper) eat refrigerated leftovers within 24 hours S/s of fluid volume overload - ANSWER ✔✔- increased, bounding pulse increased RR with SOB crackles JVD decreased HCT and BUN increased weight elevated BP angina pectoris (chest pain) - ANSWER ✔✔- retrosternal (or slightly left of sternum), radiates usu. to left shoulder and down arm into fingers; may radiate to right shoulder, neck, jaw, or epigastrium usu. lasts < 5 minutes aggravated by activity relieved by rest and nitroglycerin Infective endocarditis - ANSWER ✔✔- infection of heart lining and valves
fear of death Diagnostic enzymes for MI - ANSWER ✔✔- Creatine kinase (CK) increases in 3-6 hours, peaks 24 - 36 hours, normal by day 3 Isoenzyme (CK-MB) increases 4-8 hours, peaks in 12-24 hours, normal in 3-4 days Myoglobin increases 1-3 hours; returns to normal 12 hours after MI Troponin T and I increases 3-4 hours, peaks 4-24 hours, returns to normal in 1-3 weeks TIA - ANSWER ✔✔- transient interruption of blood flow to the brain, stroke warning sign Risk factors: AFib, high cholesterol, HTN, DM, family hx, >65 years old S/s: usu. last minutes to hours, related to location of ischemia Diagnostics: CT scan, MRI, cerebral angiography, 12 lead EKG, carotid ultrasound Magnesium sulfate AE - ANSWER ✔✔- weak or absent DTRs hypotension respiratory paralysis depressed cardiac function hypocalcemia Care: respirations should be >16 before giving IV, test knee jerk and patellar reflexes before each dose; monitor VS and I/Os SSRIs - ANSWER ✔✔- Ex: Sertraline hydrochloride, fluoxetine, citalopram, paroxetine Use: depression, OCD, obesity, bulimia AE: HA, dizziness, nervousness, N/D Insomnia or drowsiness sexual dysfunction weight gain *Take in the am
*Don't take with MAOIs or St. John's wort Care: monitor for confusion, thrombocytopenia, leukopenia, and anemia SNRIs - ANSWER ✔✔- Ex: duloxetine, venlafaxine AE: CNS depression N, HA, insomnia HTN *Use caution with pts who have seizure disorder, HTN, liver or kidney problems *Taper meds to avoid discontinuation syndrome (withdrawal) MAOIs - ANSWER ✔✔- older generation, more side effects Ex: isocarboxazid, phenelzine, tranylcypromine Use: depression, chronic pain syndromes AE: anticholinergic, effects photosensitivity sexual dysfunction weight gain orthostatic hypotension CNS stimulant hypertensive crisis - by eating foods containing tyramine or tryptophan rich foods (chocolate, aged cheese, liver, yeast, pickled products, beer, yogurt) *Avoid other MAOIs, antidepressants, OTC cold remedies *Caution with pts who have diabetes, glaucoma, HTN *need a washout period of several weeks to clear drug Serotonin syndrome symptoms - ANSWER ✔✔- agitation or restlessness insomnia
