Kaplan NCLEX Readiness Exam Questions with
Accurate Answers
A 12-year-old diagnosed boy 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?
1. "I will experience more muscle spasms and pain while my leg is in traction."
2. "I can lift my body up while I grab the overhead trapeze and bend my left leg."
3. "The health care provider told me it is okay to move the head of my bed up
and down by myself."
4. "I need to put the phone where I can reach for it without moving onto my
side." correct answer 1) CORRECT - Implementation: outcome not desired; muscle
spasm should decrease with traction; if muscle spasm pain increases, the amount
of traction weight should be assessed
2) Implementation: outcome desired; vertical movement is allowed as long as line
of pull is maintained
3) Implementation: outcome desired; balanced suspension traction not affected
by movement of bed; not affected by client movement unless line of pull affected
4) Implementation: outcome desired; can move up and down only, moving side-
to-side changes line of pull of traction
A 22-year-old woman at term comes to the hospital in labor. Two hours after
admission, the client remains 4 centimeters dilated, and her contractions are
weak. The healthcare provider orders oxytocin (Pitocin). Which finding would
require an intervention by the nurse?
,1. Contractions every 2 minutes, lasting 90 seconds.
2. Contractions every 3-4 minutes, lasting 60 seconds.
3. Fetal heart rate of 110 beats per minute at the peak of a contraction.
4. Fetal heart rate of 158 bpm at the end of a contraction. correct answer 1)
CORRECT- Assessment: outcome priority; only 30 seconds between contractions;
hypertonic labor pattern; results in fetal distress
2) Assessment: outcome not priority; normal frequency and duration
3) Assessment: outcome not priority; reassuring fetal heart tones
4) Assessment: outcome not priority; reassuring fetal heart tone
A 25-year-old multigravida client, 22 weeks gestation, calls to inform the clinic
nurse that she was exposed to rubella 2 days ago. Which statement, if made by
the nurse, is MOST appropriate?
1. "You need to see the health care provider today, but come in after hours."
2. "Come in this afternoon for your regularly scheduled appointment."
3. "You will receive the rubella vaccine during your regularly scheduled
appointment."
4. "Please cancel today's appointment and reschedule for next month." correct
answer 1) Implementation: outcome not desired; incubation period is 14-21 days,
not communicable at this time; if woman develops rubella infection during the
first trimester, abortion may be considered
,2) CORRECT-Implementation: outcome desired; communicability is approximately
7 days before to 5 days following onset of rash; client needs to be evaluated
3) Implementation: outcome: not desired; vaccination contraindicated for
pregnant women; increased risk of fetal complications
4) Implementation: outcome not desired; needs to be seen by the healthcare
provider
A 25-year-old woman is admitted to the labor unit for delivery of her first child.
Her husband is coaching her during labor. During the transitional phase of labor,
the client begins to scream and grab the side rails with each contraction. Which
action, if taken by the nurse, is MOST effective?
1. Offer the client pain medication before her next contraction.
2. Assist the client to a side-lying position with her knees flexed and a pillow
between her legs.
3. Establish eye contact with the client and breathe with her.
4. Suggest to the client that she watch television between contractions. correct
answer 1) Implementation: outcome not desired; not used during transition; not
effective and may interfere with mother's cooperation; may cause respiratory
depression in infant
2) Implementation: outcome desired but not priority; priority action is to assist
client to get control
, 3) CORRECT-Implementation: outcome desired and priority; slow breathing,
reorient; model appropriate behaviors; this will assist client to get control and
reduce muscle tension
4) Implementation: outcome desired but not priority; meet physical needs first
A 26-year-old woman comes to the emergency room for a possible ruptured
ectopic pregnancy. On admission, the client's vital signs are pulse 90, blood
pressure 110/70, respirations 20. A half-hour later, her vital signs are pulse 120,
blood pressure 86/50, respirations 26. Which of the following is the MOST
appropriate initial action for the nurse to take?
1. Administer pain medication.
2. Increase the rate of the IV fluids.
3. Ask the client to identify where she is.
4. Check the client's white cell count. correct answer 1) Implementation:
outcome not desired; address ABCs first; analgesic medication may cause further
decrease in blood pressure
2) CORRECT-Implementation: outcome desired and priority; increased pulse,
decreased BP indicates decreased intravascular volume; symptoms of
hypovolemic shock
3) Assessment: outcome desired but not priority; client in shock, implementation
required
4) Assessment: outcome desired but not priority; usually won't change unless
infection is causing septic shock
Accurate Answers
A 12-year-old diagnosed boy 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?
1. "I will experience more muscle spasms and pain while my leg is in traction."
2. "I can lift my body up while I grab the overhead trapeze and bend my left leg."
3. "The health care provider told me it is okay to move the head of my bed up
and down by myself."
4. "I need to put the phone where I can reach for it without moving onto my
side." correct answer 1) CORRECT - Implementation: outcome not desired; muscle
spasm should decrease with traction; if muscle spasm pain increases, the amount
of traction weight should be assessed
2) Implementation: outcome desired; vertical movement is allowed as long as line
of pull is maintained
3) Implementation: outcome desired; balanced suspension traction not affected
by movement of bed; not affected by client movement unless line of pull affected
4) Implementation: outcome desired; can move up and down only, moving side-
to-side changes line of pull of traction
A 22-year-old woman at term comes to the hospital in labor. Two hours after
admission, the client remains 4 centimeters dilated, and her contractions are
weak. The healthcare provider orders oxytocin (Pitocin). Which finding would
require an intervention by the nurse?
,1. Contractions every 2 minutes, lasting 90 seconds.
2. Contractions every 3-4 minutes, lasting 60 seconds.
3. Fetal heart rate of 110 beats per minute at the peak of a contraction.
4. Fetal heart rate of 158 bpm at the end of a contraction. correct answer 1)
CORRECT- Assessment: outcome priority; only 30 seconds between contractions;
hypertonic labor pattern; results in fetal distress
2) Assessment: outcome not priority; normal frequency and duration
3) Assessment: outcome not priority; reassuring fetal heart tones
4) Assessment: outcome not priority; reassuring fetal heart tone
A 25-year-old multigravida client, 22 weeks gestation, calls to inform the clinic
nurse that she was exposed to rubella 2 days ago. Which statement, if made by
the nurse, is MOST appropriate?
1. "You need to see the health care provider today, but come in after hours."
2. "Come in this afternoon for your regularly scheduled appointment."
3. "You will receive the rubella vaccine during your regularly scheduled
appointment."
4. "Please cancel today's appointment and reschedule for next month." correct
answer 1) Implementation: outcome not desired; incubation period is 14-21 days,
not communicable at this time; if woman develops rubella infection during the
first trimester, abortion may be considered
,2) CORRECT-Implementation: outcome desired; communicability is approximately
7 days before to 5 days following onset of rash; client needs to be evaluated
3) Implementation: outcome: not desired; vaccination contraindicated for
pregnant women; increased risk of fetal complications
4) Implementation: outcome not desired; needs to be seen by the healthcare
provider
A 25-year-old woman is admitted to the labor unit for delivery of her first child.
Her husband is coaching her during labor. During the transitional phase of labor,
the client begins to scream and grab the side rails with each contraction. Which
action, if taken by the nurse, is MOST effective?
1. Offer the client pain medication before her next contraction.
2. Assist the client to a side-lying position with her knees flexed and a pillow
between her legs.
3. Establish eye contact with the client and breathe with her.
4. Suggest to the client that she watch television between contractions. correct
answer 1) Implementation: outcome not desired; not used during transition; not
effective and may interfere with mother's cooperation; may cause respiratory
depression in infant
2) Implementation: outcome desired but not priority; priority action is to assist
client to get control
, 3) CORRECT-Implementation: outcome desired and priority; slow breathing,
reorient; model appropriate behaviors; this will assist client to get control and
reduce muscle tension
4) Implementation: outcome desired but not priority; meet physical needs first
A 26-year-old woman comes to the emergency room for a possible ruptured
ectopic pregnancy. On admission, the client's vital signs are pulse 90, blood
pressure 110/70, respirations 20. A half-hour later, her vital signs are pulse 120,
blood pressure 86/50, respirations 26. Which of the following is the MOST
appropriate initial action for the nurse to take?
1. Administer pain medication.
2. Increase the rate of the IV fluids.
3. Ask the client to identify where she is.
4. Check the client's white cell count. correct answer 1) Implementation:
outcome not desired; address ABCs first; analgesic medication may cause further
decrease in blood pressure
2) CORRECT-Implementation: outcome desired and priority; increased pulse,
decreased BP indicates decreased intravascular volume; symptoms of
hypovolemic shock
3) Assessment: outcome desired but not priority; client in shock, implementation
required
4) Assessment: outcome desired but not priority; usually won't change unless
infection is causing septic shock
