Kaplan NCLEX Readiness Exam.
Newest 2026-2027. Questions &
Correct Answers. Graded A
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." - ANS1) 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
1
,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. - ANS1)
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
2
,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." -
ANS1) 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
3
, 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. -
ANS1) 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?
4
Newest 2026-2027. Questions &
Correct Answers. Graded A
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." - ANS1) 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
1
,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. - ANS1)
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
2
,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." -
ANS1) 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
3
, 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. -
ANS1) 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?
4
