KAPLAN NCLEX COMPREHENSIVE TEST - Brand New Questions $ Answers 2022
1. The nurse in the psychiatric emergency room assesses 4 clients. Which of the following clients should the nurse see
FIRST?
1.A patient was raped
...
KAPLAN NCLEX COMPREHENSIVE TEST - Brand New Questions $ Answers 2022
1. The nurse in the psychiatric emergency room assesses 4 clients. Which of the following clients should the nurse see
FIRST?
1.A patient was raped 30 minutes ago and expresses feelings of selfblame, anxiety, and worthlessness.
2.A patient indicates an intent to kill himself and says he has access to a gun.
3. A patient had a miscarriage last evening and is experiencing anger and resentment.
4. A patient witnessed a child stabbed to death 2 weeks ago and is experiencing anxiety.
2. The nurse in a small town is called to a neighbor’s house in the middle of a blizzard. The neighbor woman states she is
in the 39th week of gestation with her second baby and has been having contractions for several hours. The woman has
been unable to obtain assistance because the roads are impassable. The nurse determines that the woman is in the second
stage of labor. It is MOST important for the nurse to take which of the following actions?
1.Time the frequency of the contractions.
2. Assess the type of vaginal discharge.
3. Monitor the strength of the contractions.
4. Observe the perineum.
3. The nurse receives a call from the emergency management team that 50 victims will be transported to the hospital in 15
minutes by ambulance. Which of the following actions should the nurse take FIRST?
1. Contact the nursing supervisor.
2. Tell the emergency management team they will have to reroute 25 victims.
3. Activate the hospital’s disaster plan.
4. Inform the emergency department nurses they must work overtime.
4. As a part of discharge teaching, the nurse instructs a client receiving citalopram (Celexa) 20 mg OD. The nurse determines that further teaching is necessary if the client states which of the following?"
1. "This medication helps me with my depression."
2. "I will notify my physician if I show signs of hyperactivity and mania."
3. "I will see improvement in my symptoms in 1 to 4 weeks."
4. "If I experience a fever I will take Tylenol."
5. The nurse has just received change-of-shift report. Which of the following clients should the nurse see FIRST?
1. A client diagnosed with COPD with an PaO 2 of 70%.
2. A client diagnosed with type 1 diabetes who was just informed her husband is seriously injured.
3. A client scheduled to leave for the operating room in 30 minutes for a heart valve replacement.
4. A client 10 hours postop after a right mastectomy complaining of wet sheets under her back.
6. The nurse instructs a mother of a child diagnosed with a myelomeningocele who developed an allergy to latex. The
nurse determines that teaching is effective if the mother selects which menu for her child?
1. Guacamole with pita bread, lettuce, tomato juice.
2. Poached halibut, brown rice, carrots, peach cobbler.
3. Scrambled eggs, whole wheat toast, grapes, skim milk.
4. Baked chicken leg, mashed potatoes, spinach, milkshake.
7. The nurse cares for children in the outpatient pediatric clinic. It is MOST important for the nurse to perform tuberculosis screening on which of the following children?
1. A child just returned from a 2-week trip to Europe.
2. A child recently moved to an apartment because the family lost their home.
3. A child with a new nanny who just emigrated from Latin America.
4. A child who weighed 4 lb, 10 oz at birth.
8. The nurse plans care for a patient in hemorrhagic shock from injuries sustained in a fall. It is MOST important for the
nurse to take which of the following actions?
1. Obtain vital signs.
2. Identify the source of the bleeding.
3. Elevate the head of the bed 30°.
4. Administer 0.9% NaCl IV.
9. During the change-of-shift report, the charge nurse overhears two nurses exchanging loud, rude remarks about one
nurse's excessive use of overtime. Which of the following statements by the charge nurse is MOST appropriate?
1. "I want to see both of you in my office right away."
2. "Would you please lower your voices and finish the report."
3. "I want the two of you to stop yelling and work this problem out."
4. "Both of you are good nurses and are under a lot of stress right now."
10. A 25-year-old woman is receiving aminophylline 0.7 mg/kg/h by continuous IV infusion into her left arm. It is MOST
important for the nurse to observe her for which of the following?
1. Slowed pulse and reduced blood pressure.
2. Constipation and decreased bowel sounds.
3. Palpitations and nervousness.
4. Difficulty voiding and oliguria.
11. The home care nurse visits a client diagnosed with type 1 diabetes being managed with insulin in the am and pm. The
nurse identifies that which of the following BEST measures the overall therapeutic response to management of the diabetes?
1. Glycosylated hemoglobin (HbA 1 c) 5% of total Hb.
2. Fasting blood sugar 128 mg/dL.
3. Blood pressure 130/82.
4. Serum amylase 100 Somogyi U/dL.
12. The nurse cares for a client in labor. The client's examination reveals that the cervix is 5 cm dilated and 100% effaced
and the fetal head is at -1. The membranes rupture and the nurse notes clear fluid. Which of the following actions should
the nurse take FIRST?
1. Ambulate the client for 15 minutes and evaluate the fetal heart rate every 30 minutes.
2. Prepare for delivery and notify the care provider.
3. Apply an electronic fetal monitor and start an IV.
4. Encourage the client to void every 1-2 hours and take her temperature every hour.
13. The nurse cares for a client receiving a heparin drip via an infusion pump. The physician orders warfarin (Coumadin)
5 mg PO. Which of the following actions should the nurse take NEXT?
1. Administer medication as ordered.
2. Notify the physician.
3. Check the most recent serum partial prothrombin levels.
4. Assess client for signs/symptoms of bleeding.
14. The nurse plans care for a 14-year-old hospitalized with a diagnosis of anorexia nervosa. The nurse identifies that
which of the following activities is MOST appropriate for this client?
1. Making jewelry with the occupational therapist.
2. Exercising in the physical therapy department.
3. Assisting the dietician to plan the week's menus.
4. Reading teen magazines with other patients her age
Strategy: Determine the outcome of each answer.
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