Kaplan NCLEX-RN NGN – Comprehensive Exam Study
Guide with Questions and Answers with Rationales
1. A nurse is caring for a client who suddenly develops shortness of
breath and an oxygen saturation of 86% on room air. What should
the nurse do first?
A. Obtain a complete health history
B. Apply oxygen according to the prescription/protocol
C. Notify the healthcare provider
D. Document the finding
Answer: B
Rationale: Airway and breathing take priority. The nurse should address
the client's hypoxemia immediately while continuing assessment and
escalating care as indicated.
2. A client with heart failure reports a 2.5-kg (5.5-lb) weight gain
over 3 days. Which finding is most concerning?
A. Mild fatigue
B. Increased appetite
C. Bilateral crackles
D. Dry skin
Answer: C
Rationale: Crackles can indicate pulmonary fluid accumulation from
worsening heart failure. The rapid weight gain also suggests fluid
retention.
,3. A nurse receives report on four clients. Which client should be
assessed first?
A. Client with COPD and oxygen saturation of 91% on prescribed
oxygen
B. Client 1 day after surgery requesting pain medication
C. Client with diabetes who is diaphoretic and confused
D. Client awaiting discharge instructions
Answer: C
Rationale: Diaphoresis and confusion are possible manifestations of
hypoglycemia, which can rapidly become life-threatening. Immediate
assessment and treatment are required.
4. A client receiving IV morphine becomes difficult to arouse and
has a respiratory rate of 7/min. Which medication should the nurse
anticipate administering?
A. Flumazenil
B. Naloxone
C. Protamine
D. Vitamin K
Answer: B
Rationale: Naloxone is an opioid antagonist used to reverse opioid-
induced respiratory depression.
5. Which finding is most consistent with hypokalemia?
,A. Muscle weakness
B. Hyperactive reflexes
C. Peaked T waves
D. Severe hypertension
Answer: A
Rationale: Hypokalemia can cause muscle weakness, fatigue,
constipation, and cardiac dysrhythmias. Peaked T waves are associated
with hyperkalemia.
6. A client receiving potassium chloride IV reports burning at the IV
site. What should the nurse do first?
A. Increase the infusion rate
B. Stop or pause the infusion and assess the IV site
C. Apply a heating pad
D. Flush rapidly with saline
Answer: B
Rationale: IV potassium is irritating and can cause tissue injury if
infiltration or extravasation occurs. The infusion should be stopped or
paused while the site is assessed according to facility protocol.
7. A client has a platelet count of 35,000/mm³. Which intervention is
appropriate?
A. Use an electric razor
B. Administer IM injections routinely
C. Encourage vigorous tooth brushing
D. Use rectal temperatures
, Answer: A
Rationale: Severe thrombocytopenia increases bleeding risk. An electric
razor reduces the risk of cuts. IM injections and rectal procedures should
generally be avoided when bleeding risk is significant.
8. A client with neutropenia asks how to reduce infection risk.
Which statement indicates understanding?
A. "I should avoid people who are sick."
B. "I should eat raw sprouts for extra vitamins."
C. "I can share personal hygiene items with family."
D. "I should stop washing my hands frequently."
Answer: A
Rationale: Neutropenic clients are highly susceptible to infection and
should avoid exposure to infectious individuals and practice meticulous
hygiene.
9. A client with suspected pulmonary tuberculosis is admitted.
Which precaution is appropriate?
A. Contact
B. Droplet
C. Airborne
D. Protective isolation only
Answer: C
Rationale: Tuberculosis is transmitted through airborne particles.
Appropriate respiratory protection and an airborne infection isolation
room are used according to facility policy.
Guide with Questions and Answers with Rationales
1. A nurse is caring for a client who suddenly develops shortness of
breath and an oxygen saturation of 86% on room air. What should
the nurse do first?
A. Obtain a complete health history
B. Apply oxygen according to the prescription/protocol
C. Notify the healthcare provider
D. Document the finding
Answer: B
Rationale: Airway and breathing take priority. The nurse should address
the client's hypoxemia immediately while continuing assessment and
escalating care as indicated.
2. A client with heart failure reports a 2.5-kg (5.5-lb) weight gain
over 3 days. Which finding is most concerning?
A. Mild fatigue
B. Increased appetite
C. Bilateral crackles
D. Dry skin
Answer: C
Rationale: Crackles can indicate pulmonary fluid accumulation from
worsening heart failure. The rapid weight gain also suggests fluid
retention.
,3. A nurse receives report on four clients. Which client should be
assessed first?
A. Client with COPD and oxygen saturation of 91% on prescribed
oxygen
B. Client 1 day after surgery requesting pain medication
C. Client with diabetes who is diaphoretic and confused
D. Client awaiting discharge instructions
Answer: C
Rationale: Diaphoresis and confusion are possible manifestations of
hypoglycemia, which can rapidly become life-threatening. Immediate
assessment and treatment are required.
4. A client receiving IV morphine becomes difficult to arouse and
has a respiratory rate of 7/min. Which medication should the nurse
anticipate administering?
A. Flumazenil
B. Naloxone
C. Protamine
D. Vitamin K
Answer: B
Rationale: Naloxone is an opioid antagonist used to reverse opioid-
induced respiratory depression.
5. Which finding is most consistent with hypokalemia?
,A. Muscle weakness
B. Hyperactive reflexes
C. Peaked T waves
D. Severe hypertension
Answer: A
Rationale: Hypokalemia can cause muscle weakness, fatigue,
constipation, and cardiac dysrhythmias. Peaked T waves are associated
with hyperkalemia.
6. A client receiving potassium chloride IV reports burning at the IV
site. What should the nurse do first?
A. Increase the infusion rate
B. Stop or pause the infusion and assess the IV site
C. Apply a heating pad
D. Flush rapidly with saline
Answer: B
Rationale: IV potassium is irritating and can cause tissue injury if
infiltration or extravasation occurs. The infusion should be stopped or
paused while the site is assessed according to facility protocol.
7. A client has a platelet count of 35,000/mm³. Which intervention is
appropriate?
A. Use an electric razor
B. Administer IM injections routinely
C. Encourage vigorous tooth brushing
D. Use rectal temperatures
, Answer: A
Rationale: Severe thrombocytopenia increases bleeding risk. An electric
razor reduces the risk of cuts. IM injections and rectal procedures should
generally be avoided when bleeding risk is significant.
8. A client with neutropenia asks how to reduce infection risk.
Which statement indicates understanding?
A. "I should avoid people who are sick."
B. "I should eat raw sprouts for extra vitamins."
C. "I can share personal hygiene items with family."
D. "I should stop washing my hands frequently."
Answer: A
Rationale: Neutropenic clients are highly susceptible to infection and
should avoid exposure to infectious individuals and practice meticulous
hygiene.
9. A client with suspected pulmonary tuberculosis is admitted.
Which precaution is appropriate?
A. Contact
B. Droplet
C. Airborne
D. Protective isolation only
Answer: C
Rationale: Tuberculosis is transmitted through airborne particles.
Appropriate respiratory protection and an airborne infection isolation
room are used according to facility policy.
