KAPLAN QBANK ACTUAL
EXAM COMPLETE EXAM
QUESTIONS WITH DETAILED
VERIFIED ANSWERS AND
RATIONALES\ALREADY
GRADED A+\VERIFIED BY
EXPERT
The nurse provides care for an older adult client who has chronic pain. Which question by the nurse is
best when eliciting a verbal self-report of pain?
"Are you experiencing discomfort right now?"
An older adult client diagnosed with alcohol use disorder receives chlordiazepoxide for 2 days for
symptom management. The client says to the nurse, "Get those bugs off of me!" Which action does
the nurse take?
Assess the client for tachycardia and tremors.
The nurse should assess the client for other symptoms of alcohol withdrawal, including tachycardia and
tremors. Other symptoms include fever, confusion, delusions, and hallucinations. The nurse should
notify the health care provider if the client is experiencing worsening withdrawal symptoms.
The nurse conducts an educational session on wellness. Which comment by a participant requires the
nurse to do additional teaching?
"As long as I have no diseases, I am healthy."
Health is a complex concept and means more than the absence of disease. This client needs additional
teaching.
An infant diagnosed with respiratory distress is pink in color and has a respiratory rate of 64 breaths
per minute, copious clear nasal drainage, mild nasal flaring, and a pulse oximetry reading of 95%.
Which intervention does the nurse initiate? (Select all that apply.)
,Initiate IV fluids.
The infant should be NPO due to the risk of aspiration because of the elevated respiratory rate.
Maintaining adequate hydration is imperative. Prescribed IV fluids should be initiated.
Elevate the head of the crib.
The nurse should elevate the head of the crib. Ensuring the infant is in an elevated position allows for
maximum lung expansion.
Use a bulb syringe to clear the infant's airway.
Increased airway secretions indicate the need for suctioning. This action will assist in maintaining a
patent airway.
The nurse receives a phone call from a person who states, "The client in room 203 is my family
member. Can you give me a status update?" Which response by the nurse is appropriate?..
"I am unable to give you any information at this time."
The nurse should always exercise caution about the release of information on the phone because it is
difficult to accurately identify the caller. If you are unsure, do not release any personal health
information.
The nurse provides care to a client with a closed head injury. Which assessment finding causes the
nurse to suspect that the client has developed diabetes insipidus?
Cracked lips, urinary output of 4 L/24 h with a specific gravity of 1.004.
Cracked lips, a low urine output, and a specific gravity of 1.004 when the normal specific gravity is 1.010
to 1.030 are all signs of dehydration, which occurs with diabetes insipidus.
The nurse educator prepares a class on crisis management. Which principle is important for the nurse
to emphasize when teaching this class?
One person should be in charge during a crisis.
Autocratic or directive leadership, in which the leader maintains strong control and issues commands
rather than makes suggestions or seeks input, is appropriate in a crisis or emergency situation.
A client with a history of obesity and obstructive sleep apnea reports frequent awakening in the night,
excessive daytime sleepiness, and frequent morning headaches. Which action does the nurse take
first?
Determine use of continuous positive airway pressure (CPAP) device.
The clinic nurse calls the home of a client diagnosed with type 2 diabetes. The client had blood drawn
earlier in the day, and the laboratory is reporting a blood glucose level of 475 mg/dL (26.36 mmol/L).
The nurse instructs the client to go to the emergency department immediately, but the client
responds, "I feel fine. That lab result must be a mistake." The nurse recognizes this response as
associated with which coping or protective mechanism? (Select all that apply.)
, Denial.
Denial is about protecting self from reality. For example, "That lab result is just a mistake."
The nurse provides care for a client at 25 weeks gestation. The nurse reviews the results of the client's
biophysical profile. Which fetal assessment parameter is included in the profile? (Select all that apply.)
Breathing movement.
Muscle tone.
Amniotic fluid volume.
The client will undergo ultrasonography to obtain four of the five biophysical profile parameters,
including assessing amniotic fluid volume. There should be a single vertical pocket greater than 2 cm and
an amniotic fluid index greater than 5 cm.
Assessment of fetal well-being requires evaluation of several parameters, including fetal breathing
movement, general movements, fetal tone, amniotic fluid index, and a nonstress test. You should
understand that a biophysical profile is conducted using a combination of ultrasound and fetal heart
rate monitoring. You are aware that a client undergoing this procedure so early in pregnancy will require
emotional support because it is not usually done at that time, unless there is suspicion of decreased
fetal well-being.
A client has a cervical spine immobilization device on. The health care provider prescribes strict body
alignment via log roll technique. Which action does the nurse take?
The nurse asks two other nursing personnel to assist with log roll turning.
The nurse prepares a transdermal fentanyl patch for a client with cancer pain. Which action does the
nurse take when applying the patch on the client? (Select all that apply.)
Avoid a skin area that has abrasions.
Select an area of the skin that has no hair.
Apply gloves before preparing the medication.
Cleanse the skin of the previously applied patch.
Remove the previous patch and fold it with the medication side in
A client admitted to the hospital receives a diagnosis of hepatitis B. On which factors will the nurse
base the plan of care?
Blood and body fluids of an infected individual can be contagious.
Hepatitis B is very contagious in a hospital setting due to risk of contact with blood and body fluids.
The nurse completes a surgical hand scrub before each procedure. In which order, starting with the
first step, does the nurse implement the surgical hand scrub? (Please arrange in order. All options
must be used.)
Remove bracelets, rings, and watches.
Turn on water using knee or foot control.
Clean under the nails of both hands with disposable nail pick.
EXAM COMPLETE EXAM
QUESTIONS WITH DETAILED
VERIFIED ANSWERS AND
RATIONALES\ALREADY
GRADED A+\VERIFIED BY
EXPERT
The nurse provides care for an older adult client who has chronic pain. Which question by the nurse is
best when eliciting a verbal self-report of pain?
"Are you experiencing discomfort right now?"
An older adult client diagnosed with alcohol use disorder receives chlordiazepoxide for 2 days for
symptom management. The client says to the nurse, "Get those bugs off of me!" Which action does
the nurse take?
Assess the client for tachycardia and tremors.
The nurse should assess the client for other symptoms of alcohol withdrawal, including tachycardia and
tremors. Other symptoms include fever, confusion, delusions, and hallucinations. The nurse should
notify the health care provider if the client is experiencing worsening withdrawal symptoms.
The nurse conducts an educational session on wellness. Which comment by a participant requires the
nurse to do additional teaching?
"As long as I have no diseases, I am healthy."
Health is a complex concept and means more than the absence of disease. This client needs additional
teaching.
An infant diagnosed with respiratory distress is pink in color and has a respiratory rate of 64 breaths
per minute, copious clear nasal drainage, mild nasal flaring, and a pulse oximetry reading of 95%.
Which intervention does the nurse initiate? (Select all that apply.)
,Initiate IV fluids.
The infant should be NPO due to the risk of aspiration because of the elevated respiratory rate.
Maintaining adequate hydration is imperative. Prescribed IV fluids should be initiated.
Elevate the head of the crib.
The nurse should elevate the head of the crib. Ensuring the infant is in an elevated position allows for
maximum lung expansion.
Use a bulb syringe to clear the infant's airway.
Increased airway secretions indicate the need for suctioning. This action will assist in maintaining a
patent airway.
The nurse receives a phone call from a person who states, "The client in room 203 is my family
member. Can you give me a status update?" Which response by the nurse is appropriate?..
"I am unable to give you any information at this time."
The nurse should always exercise caution about the release of information on the phone because it is
difficult to accurately identify the caller. If you are unsure, do not release any personal health
information.
The nurse provides care to a client with a closed head injury. Which assessment finding causes the
nurse to suspect that the client has developed diabetes insipidus?
Cracked lips, urinary output of 4 L/24 h with a specific gravity of 1.004.
Cracked lips, a low urine output, and a specific gravity of 1.004 when the normal specific gravity is 1.010
to 1.030 are all signs of dehydration, which occurs with diabetes insipidus.
The nurse educator prepares a class on crisis management. Which principle is important for the nurse
to emphasize when teaching this class?
One person should be in charge during a crisis.
Autocratic or directive leadership, in which the leader maintains strong control and issues commands
rather than makes suggestions or seeks input, is appropriate in a crisis or emergency situation.
A client with a history of obesity and obstructive sleep apnea reports frequent awakening in the night,
excessive daytime sleepiness, and frequent morning headaches. Which action does the nurse take
first?
Determine use of continuous positive airway pressure (CPAP) device.
The clinic nurse calls the home of a client diagnosed with type 2 diabetes. The client had blood drawn
earlier in the day, and the laboratory is reporting a blood glucose level of 475 mg/dL (26.36 mmol/L).
The nurse instructs the client to go to the emergency department immediately, but the client
responds, "I feel fine. That lab result must be a mistake." The nurse recognizes this response as
associated with which coping or protective mechanism? (Select all that apply.)
, Denial.
Denial is about protecting self from reality. For example, "That lab result is just a mistake."
The nurse provides care for a client at 25 weeks gestation. The nurse reviews the results of the client's
biophysical profile. Which fetal assessment parameter is included in the profile? (Select all that apply.)
Breathing movement.
Muscle tone.
Amniotic fluid volume.
The client will undergo ultrasonography to obtain four of the five biophysical profile parameters,
including assessing amniotic fluid volume. There should be a single vertical pocket greater than 2 cm and
an amniotic fluid index greater than 5 cm.
Assessment of fetal well-being requires evaluation of several parameters, including fetal breathing
movement, general movements, fetal tone, amniotic fluid index, and a nonstress test. You should
understand that a biophysical profile is conducted using a combination of ultrasound and fetal heart
rate monitoring. You are aware that a client undergoing this procedure so early in pregnancy will require
emotional support because it is not usually done at that time, unless there is suspicion of decreased
fetal well-being.
A client has a cervical spine immobilization device on. The health care provider prescribes strict body
alignment via log roll technique. Which action does the nurse take?
The nurse asks two other nursing personnel to assist with log roll turning.
The nurse prepares a transdermal fentanyl patch for a client with cancer pain. Which action does the
nurse take when applying the patch on the client? (Select all that apply.)
Avoid a skin area that has abrasions.
Select an area of the skin that has no hair.
Apply gloves before preparing the medication.
Cleanse the skin of the previously applied patch.
Remove the previous patch and fold it with the medication side in
A client admitted to the hospital receives a diagnosis of hepatitis B. On which factors will the nurse
base the plan of care?
Blood and body fluids of an infected individual can be contagious.
Hepatitis B is very contagious in a hospital setting due to risk of contact with blood and body fluids.
The nurse completes a surgical hand scrub before each procedure. In which order, starting with the
first step, does the nurse implement the surgical hand scrub? (Please arrange in order. All options
must be used.)
Remove bracelets, rings, and watches.
Turn on water using knee or foot control.
Clean under the nails of both hands with disposable nail pick.
