1
Kaplan Fundamentals Integrated Exam
Questions 1–200 | Advanced / Hard Level |
Nursing Students Target | 100% Pass
Guaranteed | Graded A+
1 The nurse is performing a sterile wound dressing change for a client with a surgical incision.
Which of the following actions indicates a break in sterile technique?
A. The nurse holds sterile forceps with the tips pointing downward
B. The nurse keeps the sterile field within their line of sight
C. The nurse places the sterile dressing within 1 inch of the sterile field's edge
D. The nurse opens the sterile package away from their body
Correct Answer: C
Explanation: The outer 1-inch border of a sterile field is considered contaminated. Placing sterile
items within this border is a break in sterile technique. Forceps tips pointing downward (A)
allows fluid to drain away from the tips, maintaining sterility. Keeping the field in sight (B) and
opening packages away from the body (D) are correct sterile technique practices.
,2
2 A nurse is caring for a client who is receiving continuous enteral feedings via a nasogastric
tube. Which of the following is the priority nursing intervention to prevent aspiration?
A. Flush the tube with 30 mL of water every 4 hours
B. Keep the head of the bed elevated to at least 30 degrees
C. Check the pH of gastric aspirate
D. Change the feeding bag every 24 hours
Correct Answer: B
Explanation: Keeping the head of the bed elevated to at least 30 degrees (preferably 45
degrees) is the priority intervention to prevent aspiration during enteral feedings. Flushing the
tube (A) maintains patency. Checking gastric pH (C) verifies tube placement. Changing the
feeding bag (D) prevents contamination.
3 The nurse is preparing to administer an intramuscular (IM) injection using the ventrogluteal
site. Which of the following is the correct landmark for this site?
A. The midpoint of a line between the greater trochanter and the iliac crest
B. The center of the deltoid muscle
,3
C. The upper outer quadrant of the buttock
D. The midpoint of the vastus lateralis muscle
Correct Answer: A
Explanation: The ventrogluteal site is located by placing the palm on the greater trochanter, the
index finger on the anterior superior iliac spine, and the middle finger toward the iliac crest,
forming a V. The injection is given at the midpoint of this V. The deltoid (B), upper outer
quadrant of the buttock (C) (which is the dorsogluteal site, not recommended), and vastus
lateralis (D) are other IM sites.
4 A client with a history of heart failure is receiving digoxin. The nurse notes a heart rate of 52
bpm and the client reports nausea. Which of the following is the priority nursing action?
A. Administer the digoxin as prescribed
B. Hold the digoxin and notify the provider
C. Administer an antiemetic for the nausea
D. Check the client's serum potassium level
Correct Answer: B
Explanation: A heart rate below 60 bpm and nausea are signs of digoxin toxicity. The priority is
, 4
to hold the medication and notify the provider. Administering the medication (A) could worsen
toxicity. Administering an antiemetic (C) does not address the underlying cause. Checking serum
potassium (D) is important but is not the priority action.
5 The nurse is reinforcing teaching with a client who has a new prescription for a metered-dose
inhaler (MDI). Which of the following instructions should the nurse include?
A. "Inhale the medication, then exhale completely before pressing the canister."
B. "Press the canister down as you breathe in slowly and deeply."
C. "Hold your breath for 1 to 2 seconds after inhaling."
D. "Use the inhaler only when you are having an asthma attack."
Correct Answer: B
Explanation: The correct technique for using an MDI is to press the canister down while taking a
slow, deep breath. Exhaling completely (A) should occur before placing the inhaler in the mouth.
Breath-holding should be for 5-10 seconds (C), not 1-2. MDIs are used for both maintenance and
acute treatment (D).
Kaplan Fundamentals Integrated Exam
Questions 1–200 | Advanced / Hard Level |
Nursing Students Target | 100% Pass
Guaranteed | Graded A+
1 The nurse is performing a sterile wound dressing change for a client with a surgical incision.
Which of the following actions indicates a break in sterile technique?
A. The nurse holds sterile forceps with the tips pointing downward
B. The nurse keeps the sterile field within their line of sight
C. The nurse places the sterile dressing within 1 inch of the sterile field's edge
D. The nurse opens the sterile package away from their body
Correct Answer: C
Explanation: The outer 1-inch border of a sterile field is considered contaminated. Placing sterile
items within this border is a break in sterile technique. Forceps tips pointing downward (A)
allows fluid to drain away from the tips, maintaining sterility. Keeping the field in sight (B) and
opening packages away from the body (D) are correct sterile technique practices.
,2
2 A nurse is caring for a client who is receiving continuous enteral feedings via a nasogastric
tube. Which of the following is the priority nursing intervention to prevent aspiration?
A. Flush the tube with 30 mL of water every 4 hours
B. Keep the head of the bed elevated to at least 30 degrees
C. Check the pH of gastric aspirate
D. Change the feeding bag every 24 hours
Correct Answer: B
Explanation: Keeping the head of the bed elevated to at least 30 degrees (preferably 45
degrees) is the priority intervention to prevent aspiration during enteral feedings. Flushing the
tube (A) maintains patency. Checking gastric pH (C) verifies tube placement. Changing the
feeding bag (D) prevents contamination.
3 The nurse is preparing to administer an intramuscular (IM) injection using the ventrogluteal
site. Which of the following is the correct landmark for this site?
A. The midpoint of a line between the greater trochanter and the iliac crest
B. The center of the deltoid muscle
,3
C. The upper outer quadrant of the buttock
D. The midpoint of the vastus lateralis muscle
Correct Answer: A
Explanation: The ventrogluteal site is located by placing the palm on the greater trochanter, the
index finger on the anterior superior iliac spine, and the middle finger toward the iliac crest,
forming a V. The injection is given at the midpoint of this V. The deltoid (B), upper outer
quadrant of the buttock (C) (which is the dorsogluteal site, not recommended), and vastus
lateralis (D) are other IM sites.
4 A client with a history of heart failure is receiving digoxin. The nurse notes a heart rate of 52
bpm and the client reports nausea. Which of the following is the priority nursing action?
A. Administer the digoxin as prescribed
B. Hold the digoxin and notify the provider
C. Administer an antiemetic for the nausea
D. Check the client's serum potassium level
Correct Answer: B
Explanation: A heart rate below 60 bpm and nausea are signs of digoxin toxicity. The priority is
, 4
to hold the medication and notify the provider. Administering the medication (A) could worsen
toxicity. Administering an antiemetic (C) does not address the underlying cause. Checking serum
potassium (D) is important but is not the priority action.
5 The nurse is reinforcing teaching with a client who has a new prescription for a metered-dose
inhaler (MDI). Which of the following instructions should the nurse include?
A. "Inhale the medication, then exhale completely before pressing the canister."
B. "Press the canister down as you breathe in slowly and deeply."
C. "Hold your breath for 1 to 2 seconds after inhaling."
D. "Use the inhaler only when you are having an asthma attack."
Correct Answer: B
Explanation: The correct technique for using an MDI is to press the canister down while taking a
slow, deep breath. Exhaling completely (A) should occur before placing the inhaler in the mouth.
Breath-holding should be for 5-10 seconds (C), not 1-2. MDIs are used for both maintenance and
acute treatment (D).
