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KAPLAN NCLEX® READINESS EXAM ACTUAL TEST COMPLETE QUESTIONS AND CORRECT DETAILED ANSWERS, Exams of Nursing

Johns Hopkins University (JHU)Nursing

KAPLAN NCLEX® READINESS EXAM ACTUAL TEST COMPLETE QUESTIONS AND CORRECT DETAILED ANSWERS (CORRECT VERIFIED SOLUTIONS) A NEW UPDATED VERSION |GUARANTEED PASS A+ (BRAND NEW!!) FULL REVISED The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the nurse notes that the client's tracheostomy cuff is inflated. Which of the following is the MOST appropriate action for the nurse to take? 1. Leave the cuff inflated and suction through the tracheostomy. 2. Deflate the cuff and suction through the tracheostomy tube. 3. Inflate the cuff pressure to 40 mm Hg before suctioning. 4. Adjust the wall suction pressure to 160 to 180 mm Hg before suctioning. - CORRECT ANSWER >>>1) CORRECT - Implementation: outcome desired; cuff inflation decreases the risk of aspiration; cuff position and pressure should be assessed frequently; swallowing and breathing will cause tracheostomy tube movement

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KAPLAN NCLEX® READINESS EXAM ACTUAL TEST

COMPLETE QUESTIONS AND CORRECT DETAILED

ANSWERS (CORRECT VERIFIED SOLUTIONS) A NEW

UPDATED VERSION |GUARANTEED PASS A+ (BRAND

NEW!!) FULL REVISED

The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the

nurse notes that the client's tracheostomy cuff is inflated. Which of the following is the MOST

appropriate action for the nurse to take?

1. Leave the cuff inflated and suction through the tracheostomy.

2. Deflate the cuff and suction through the tracheostomy tube.

3. Inflate the cuff pressure to 40 mm Hg before suctioning.

4. Adjust the wall suction pressure to 160 to 180 mm Hg before suctioning. - CORRECT

ANSWER >>>1) CORRECT - Implementation: outcome desired; cuff inflation decreases the risk

of aspiration; cuff position and pressure should be assessed frequently; swallowing and

breathing will cause tracheostomy tube movement

2) Implementation: outcome not desired; accumulated oral secretions above the cuff will drain

into the bronchi; increased risk of infection

3) Implementation: outcome not desired; cuff pressure should be less than 20 mm Hg (25 cm

H2O); risk of trauma to trachea with higher pressures

4) Implementation: outcome not desired; increases the risk of trauma to lower airways

Partial preview of the text

Download KAPLAN NCLEX® READINESS EXAM ACTUAL TEST COMPLETE QUESTIONS AND CORRECT DETAILED ANSWERS and more Exams Nursing in PDF only on Docsity!

KAPLAN NCLEX® READINESS EXAM ACTUAL TEST

COMPLETE QUESTIONS AND CORRECT DETAILED

ANSWERS (CORRECT VERIFIED SOLUTIONS) A NEW

UPDATED VERSION |GUARANTEED PASS A+ (BRAND

NEW!!) FULL REVISED

The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the nurse notes that the client's tracheostomy cuff is inflated. Which of the following is the MOST appropriate action for the nurse to take?

Leave the cuff inflated and suction through the tracheostomy.
Deflate the cuff and suction through the tracheostomy tube.
Inflate the cuff pressure to 40 mm Hg before suctioning.
Adjust the wall suction pressure to 160 to 180 mm Hg before suctioning. - CORRECT ANSWER >>> 1) CORRECT - Implementation: outcome desired; cuff inflation decreases the risk of aspiration; cuff position and pressure should be assessed frequently; swallowing and breathing will cause tracheostomy tube movement

Implementation: outcome not desired; accumulated oral secretions above the cuff will drain into the bronchi; increased risk of infection
Implementation: outcome not desired; cuff pressure should be less than 20 mm Hg (25 cm H2O); risk of trauma to trachea with higher pressures
Implementation: outcome not desired; increases the risk of trauma to lower airways

A young adult brings a friend to the emergency department and states that the friend has been using heroin. Which action by the nurse is the MOST appropriate?

Assess pupil size and reactivity.
Assess oxygen saturation levels.
Palpate dorsalis pedis pulses.
Ask the client if he knows today's date. - CORRECT ANSWER >>> 1) Assessment: outcome not priority but may be appropriate; pinpoint pupils are a sign of heroin overdose

CORRECT - Assessment: outcome priority; shallow respirations seen; impaired alveolar gas exchange and possible respiratory arrest
Assessment: outcome not priority; most important to assess airway and breathing
Assessment: outcome not priority but may be appropriate; drowsiness and euphoria may be seen; not priority The client tells the clinic nurse that the client is thinking about using nicotine polacrilex (Nicorette). Which question is MOST important for the nurse to ask?

"Have you tried other methods to stop smoking?"
"How long have you been smoking?"
"Have you ever had chest pain?"
"Do you have a partial dental bridge?" - CORRECT ANSWER >>> 1) Assessment: outcome not priority but may be appropriate; can be asked as part of assessment

Assessment: outcome not priority but may be appropriate; should be assessed for further teaching

A pregnant woman receives an epidural anesthetic. After administration of the epidural anesthetic, the client's blood pressure changes from 120/84 to 94/50. Which action by the nurse is MOST appropriate?

Place the client flat on her back.
Elevate the head of the bed 30 degrees.
Place the client on her left side with her legs flexed.
Place the client supine with the foot of the bed elevated. - CORRECT ANSWER >>> 1) Implementation: outcome not desired; no increase in venous return

Implementation: outcome not desired; will decrease venous return
CORRECT - Implementation: outcome desired; will increase venous return and cardiac output; fetal pressure on inferior vena cava reduced
Implementation: outcome not desired; elevation of legs will increase venous return, but fetal pressure on vena cava will prevent blood return to heart A nursing order, "Increase fluid intake" is written for a client diagnosed with dehydration. Which finding BEST indicates improving fluid status?

Urinary output of 1,500 mL in 24 hours.
Serum hematocrit 52%.
Oral fluid intake of 900 mL in 24 hours.
Blood pressure of 100/82. - CORRECT ANSWER >>> 1) CORRECT - Assessment: outcome priority; increased amounts of antidiuretic hormone secreted; urine output decreased and concentrated

Assessment: outcome not priority; indicates that blood is hemoconcentrated
Assessment: outcome not priority; normal intake is 1,500 mL in 24 hours
Assessment: outcome not priority; normal BP is 120/ The nurse prepares to administer the initial dose of oral enalapril (Vasotec) 20 mg in the morning. Which medication should the nurse question giving to the client?

20 mg oral escitalopram (Celexa) in the morning.
40 mg oral furosemide (Lasix) in the morning.
300 mg of oral gabapentin (Neurontin) twice daily.
10 mg zolpidem (Ambien) at bedtime. - CORRECT ANSWER >>> 1) Implementation: outcome not a problem; no interaction with ACE inhibitors; is an SSRI antidepressant

CORRECT - Implementation: outcome potential problem; 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
Implementation: outcome not a problem; no interaction; gabapentin classified as antiseizure medication; off-label use for neuropathic pain
Implementation: outcome not a problem; is a hypnotic; no interaction with ACE inhibitors The home care nurse visits a client with a halo fixator traction device. Which client statement MOST concerns the nurse?

Assessment: outcome not desired; is a sign of anxiety The nurse on the maternity unit must accept a transfer client from a medical/surgical unit. The nurse considers which transfer client appropriate?

A 38-year-old client with a diagnosis of systemic lupus erythematosus.
A 45-year-old client receiving daily external radiation therapy treatments for breast cancer.
A 58-year-old client receiving antibiotic treatment for cellulitis of the left leg.
A 74-year-old client who has received intravenous antibiotics for 7 days. - CORRECT ANSWER >>> 1) CORRECT - Implementation: outcome desired; autoimmune disease; not infectious

Implementation: outcome not desired; possible skin damage and suppression of bone marrow with decreased white-blood-cell levels; increased risk for infection
Implementation: outcome not desired; generalized skin infection of deeper connective tissue; usually caused by Streptococcus or Staphylococcus; increased risk for infection
Implementation: outcome not desired; elderly clients receiving long-term antibiotic therapy are at risk for Clostridium difficile infection; highly contagious; increased risk for infection The nurse in the outclient surgery unit prepares a 4-year-old child for surgery. It is MOST important for the nurse to make which of these statements?

"Your parents are going to leave a half hour before the surgery."
"You're going to talk with some other children who had this surgery."
"If you have this surgery, your parents will buy you a new toy."

"Take this doll and show me where the operation will be done." **- CORRECT ANSWER

** 1) Implementation: outcome not desired; parents are encouraged to remain with child

Implementation: outcome not desired; appropriate only for school-aged and adolescent children
Implementation: outcome not desired; not appropriate
CORRECT - Implementation: outcome desired; encourage expression of feelings (e.g., anger); fear mutilation; allow child to play with models of equipment The nurse cares for a client diagnosed with Alzheimer's disease. The client is confused and incontinent of urine. What is the MOST important action for the nurse to take?

Insert an indwelling urinary drainage catheter.
Perform intermittent catheterization every 4 hours.
Offer the bedpan to the client every 2 hours.
Assist the client to a bedside commode every 2 hours. - CORRECT ANSWER >>> 1) Implementation: outcome not desired; increases risk of infection; catheter-related infections are most common hospital-acquired infection

Implementation: outcome not desired; increases chance of infection
Implementation: outcome appropriate but not priority; does not keep client independent and active
CORRECT - Implementation: outcome desired; keeps client active and independent

Do not administer the Ceclor or naproxen; notify the healthcare provider. - CORRECT ANSWER >>> 1) Implementation: outcome not desired; cephalosporins have cross-allergies with penicillins

Implementation: outcome not desired; NSAIDs should be used cautiously with aspirin allergies
Implementation: outcome not desired; both medications should be withheld due to allergies
CORRECT - Implementation: outcome desired; both medications should be withheld; risk of hypersensitivity reaction 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?

"The skin around the stoma should be cleaned with warm water and thoroughly dried."
"The appliance should fit snugly around the ileostomy opening."
"I should take polyethylene glycol (MiraLax) with a large glass of water."
"I will continue to take a daily multi-vitamin." - CORRECT ANSWER >>> 1) Implementation: outcome desired; standard of care for ileostomy

Implementation: outcome desired; ileostomy drainage is liquid and very alkaline; great risk of skin irritation
CORRECT - Implementation: outcome not desired; osmotic laxative and is contraindicated; avoid enteric-coated or capsule medication, which may not be absorbed through GI tract
Implementation: outcome desired; inform healthcare provider and pharmacist about ileostomy

The nurse cares for a client diagnosed with chronic bronchitis and peripheral vascular disease. The nurse expects to assess which of these breath sounds?

Continuous, high-pitched musical sounds heard on expiration.
Soft, high-pitched interrupted sounds heard on inspiration.
Deep, low-pitched rumbling sounds are heard mainly on expiration.
Harsh, grating sounds heard best during inspiration. - CORRECT ANSWER >>> 1) Assessment: outcome not expected; sibilant wheezes, heard with asthma, caused by narrow bronchioles

Assessment: outcome not expected; crackles, heard with pneumonia and CHF, caused by fluid in the alveoli
CORRECT - Assessment: outcome expected; sonorous wheezes or rhonchi, caused by mucus in the airways; excessive mucous production is primary symptom
Assessment: outcome not expected; pericardial friction rub, caused by inflamed pleura or pericarditis The nurse prepares to administer gentamicin (Garamycin) to the 65-year-old client. Which is the MOST important action for the nurse to take prior to administration of the medication?

Request a daily hemoglobin and hematocrit test.
Monitor the serum BUN and creatinine.
Request a highly-sensitive C-reactive protein (hs-CRP) test.
Monitor the erythrocyte sedimentation rate (ESR). - CORRECT ANSWER >>> 1) Assessment: outcome not priority; may cause anemia, but not usually seen

The nurse cares for the client diagnosed with lung cancer. The family states that the client has become confused and that urinary output has decreased during the previous 24 hours. Which finding MOST concerns the nurse?

2+ pitting pretibial edema.
Sodium 128 mEq/L.
Weight gain of 2 kg in 24 hours.
Urine specific gravity 1.008. - CORRECT ANSWER >>> 1) Assessment: outcome desired but not priority; edema not seen with SIADH even though water is retained; needs to be monitored

CORRECT - Assessment: outcome desired and priority; normal sodium range is 135- 145 mEq/L, dilutional hyponatremia due to SIADH; client is neurologically depressed with increased risk of seizures
Asssessment: outcome desired but not priority; indicates fluid retention, not as important as hyponatremia; important to watch trends in weight
Assessment: outcome not desired; 1.008 indicates that urine is very dilute; with SIADH, urine will have high concentration and specific gravity due to excess ADH secretion The home care nurse cares for a client who is diagnosed with hypertension and mild depression. The client's daughter states that her mother has been falling frequently. WWhich response by the nurse is BEST?

"Let's get your mother a walker."
"Do you think it's time to put your mother in a nursing home?"
"When does your mother fall?"
"Does your mother seem to be more confused lately?" - CORRECT ANSWER >>> 1) Implementation: outcome not desired; need to assess first

Assessment: outcome not priority; "yes/no" question; doesn't help determine the problem
CORRECT - Assessment: outcome priority; nurse needs to determine what the problem is before implementing; recent history of falling is most important contributor to increased risk of falls
Assessment: outcome not priority; "yes/no" question is non-therapeutic; need to assess; may be a contributing factor A femoral angiogram is scheduled for a client. It is MOST important for the nurse to take which action prior to the angiogram?

Clean and shave the catheter insertion-site area.
Locate and note the presence of peripheral pulses.
Encourage the client to increase oral fluid intake.
Teach coughing and deep-breathing exercises. - CORRECT ANSWER >>> 1) Implementation: outcome not desired; cleansing may be done according to facility policy; shaving may not be recommended due to possible abrasions and increased risk of infection

CORRECT - Assessment: outcome desired and priority; pulse location may be marked according to facility policy; important to get baseline assessment of color, motion, temperature and sensitivity of extremities as well as strength and equality of pulses
Implementation: outcome not desired; NPO 8 hours prior to test; dye may cause possible nausea; fluid intake should be increased after procedure to clear dye and reduce risk of renal toxicity

Provide the client with newspapers and magazines.
Assign a staff member to check on the client every 15 minutes. - CORRECT ANSWER >>> 1) Implementation: outcome not desired; does not address orientation needs; risk of overstimulation; television should be on intermittently

CORRECT - Implementation: outcome desired; provides for safety needs and frequent orientation
Implementation: outcome not priority; does not address safety needs or orientation
Implementation: outcome desired not priority; addresses safety but not orientation or stimulation needs The nurse is responsible for triage of injured residents of an apartment building that collapsed during a tornado. Which client should the emergency personnel see FIRST?

A 38-year-old client with potential fracture left femur. Blood pressure 110/78, pulse 92/minute, shallow respirations at 16/minute.
A 42-year-old client with ecchymotic areas on the left anterior and posterior chest. Blood pressure 142/90, pulse 88/minute, shallow respirations at 20/minute.
A 48-year-old client with severe head trauma. Blood pressure 168/52, pulse 58 per minute, irregular respirations at 12/minute.
A 64-year-old client complaining of left hand and wrist pain asking, "Where am I?" Blood pressure 128/72, pulse 88/minute, respirations unlabored at 16/minute. **- CORRECT ANSWER

** 1) Potential for hemorrhage or fatty embolism; eliminate second

Potential pneumothorax; see second

CORRECT - Real problem; vitals signs indicate significant increase in intracranial pressure; most unstable client
Most stable client; eliminate first The nurse cares for a client diagnosed with Crohn's disease. The nurse instructs the client about diet. Which menu selection indicates to the nurse that teaching is effective?

Cheeseburger on a whole-wheat bun, french fries, and an apple.
Tomato soup, saltines, and a slice of unfrosted angel food cake.
Baked cod, biscuit without butter, fruit roll-up.
Macaroni and cheese, coleslaw, 2 macaroon cookies. - CORRECT ANSWER >>> 1) Implementation: outcome not desired; high-fat, high-protein, high-residue; high-residue contraindicated

Implementation: outcome not desired; low-fat, low-protein, low-residue
CORRECT - Implementation: outcome desired; low-fat, high-protein, low-residue, nonirritating, high in calories, minerals
Implementation: outcome not desired; high-fat, low-protein, high-residue; may cause diarrhea The nursing team consists of one RN, one LPN/LVN and two nursing assistive personnel (NAPs). Which assignment is MOST appropriate for the LPN/LVN?

A 38-year-old client diagnosed with Guillain-Barré syndrome receiving plasmapheresis therapy.

Implementation: outcome not desired; invasive procedure should be avoided if possible
Implementation: outcome not desired; would change the results of the 24-hour urine sample; all urine must be collected for accuracy The nurse cares for the client in the recovery room after a knee surgery procedure. The client has an oral airway in place. Which is the BEST indicator that the oral airway can be removed?

The client has a forceful cough during re-positioning.
The client responds to to a normal spoken voice.
The client tries to chew on the oral airway.
The client is able to swallow. - CORRECT ANSWER >>> 1) Assessment: outcome not priority; may cough due to irritation of the airway; does not reflect client responsiveness

CORRECT - Assessment: outcome priority; client is alert and able to maintain his own airway
Assessment: outcome not priority; client needs to be responsive before airway is removed; may be a reflexive action
Assessment: outcome not priority; client will be able to swallow before he is responsive The nurse cares for clients in the antepartum clinic. Which client should the nurse see FIRST?

An 18-year-old multigravida client at 28 weeks gestation with a positive indirect Coombs' test.
A 24-year-old multigravida client at 32 weeks gestation with moderate facial edema.

A 30-year-old client at 26 weeks gestation with bilateral yellow breast exudate.
A 43-year-old primigravida client at 18 weeks of gestation reporting an absence of fetal movement. - CORRECT ANSWER >>> 1) Outcome not priority; indicates that Rh antibodies present; needs further investigation

CORRECT - Outcome priority; indicates pre-eclampsia; requires immediate evaluation; is at risk for complications
Outcome not priority; colostrum may leak from breast during pregnancy; normal finding
Outcome not priority; normal finding; quickening doesn't occur before 18 weeks in primagravidas; 20 weeks in multigravidas The nurse instructs a client about include digoxin (Lanoxin), furosemide (Lasix), spironolactone (Aldactone), and a low-sodium diet. Which statement by the client indicates the need for further instruction?

"I should weigh myself every morning and call the health care provider if I gain more than a couple of pounds in a few days."
"I should call the health care provider immediately if I start to feel nauseated or have difficulty breathing with normal activities."
"I plan to use salt substitutes now that I have to limit my sodium intake."
"I should read food and nonprescription medication labels to check the ingredients." - CORRECT ANSWER >>> 1) Implementation: outcome desired; would indicate fluid retention

Implementation: outcome desired; symptoms of digitalis toxicity, CHF
CORRECT - Implementation: outcome not desired; salt substitutes contain potassium; spironolactone is a potassium-sparing diuretic

KAPLAN NCLEX® READINESS EXAM ACTUAL TEST COMPLETE QUESTIONS AND CORRECT DETAILED ANSWERS, Exams of Nursing

Related documents

Partial preview of the text

Download KAPLAN NCLEX® READINESS EXAM ACTUAL TEST COMPLETE QUESTIONS AND CORRECT DETAILED ANSWERS and more Exams Nursing in PDF only on Docsity!

KAPLAN NCLEX® READINESS EXAM ACTUAL TEST

COMPLETE QUESTIONS AND CORRECT DETAILED

ANSWERS (CORRECT VERIFIED SOLUTIONS) A NEW

UPDATED VERSION |GUARANTEED PASS A+ (BRAND

NEW!!) FULL REVISED