1
Kaplan NCLEX-RN Question Trainer #1 | 50
Comprehensive Nursing Questions and Rationales
KAPLAN NCLEX-RN QUESTION TRAINER #1
50 Comprehensive Nursing Questions with Detailed Rationales
1. The nurse is caring for a patient who returned from a cardiac catheterization
via the right femoral artery. Which finding requires immediate intervention?
A. A small bruise at the puncture site
B. Pain rated 3 on a 0–10 scale at the site
C. A hard, expanding mass at the puncture site with ecchymosis
D. Dorsalis pedis pulse 2+ on the affected side
: Correct Answer : C
Rationale: A hard, expanding mass accompanied by ecchymosis indicates a
retroperitoneal or arterial bleed and possible pseudoaneurysm; this is a
life-threatening emergency requiring immediate pressure and surgical
notification. A small bruise and mild pain are expected. A dorsalis pedis pulse of
2+ is a normal finding. The priority is recognizing the expanding hematoma as a
sign of active bleeding.
2. The nurse is preparing to administer a unit of packed red blood cells to a
patient. Which action should the nurse take first?
A. Check the patient’s vital signs
B. Verify the blood product with another licensed nurse at the bedside
C. Initiate the infusion slowly
D. Pre-medicate with acetaminophen
: Correct Answer : B
Rationale: The first priority in blood administration is verification of the patient’s
identity and the blood product. Two licensed nurses must check the patient’s ID
band, blood bag label, and transfusion order at the bedside to prevent a
pg. 1
,2
hemolytic transfusion reaction. Vital signs are obtained before, during, and after
the infusion, but verification is the initial step. Pre-medication may be ordered
but is not the first action.
3. A patient is admitted with a diagnosis of right-sided heart failure. Which
assessment finding does the nurse expect?
A. Pulmonary crackles
B. Orthopnea
C. Jugular vein distention
D. Frothy sputum
: Correct Answer : C
Rationale: Right-sided heart failure causes systemic venous congestion, resulting
in jugular vein distention, hepatomegaly, ascites, and peripheral edema.
Left-sided failure causes pulmonary congestion, crackles, orthopnea, and frothy
sputum. Recognizing the difference guides monitoring and treatment.
4. The nurse is teaching a patient about a new prescription for warfarin. Which
statement by the patient indicates a need for further teaching?
A. “I will use an electric razor for shaving.”
B. “I will avoid eating large amounts of green leafy vegetables.”
C. “I will take aspirin for headaches if I need pain relief.”
D. “I will report any signs of bleeding, such as bruising or blood in my urine.”
: Correct Answer : C
Rationale: Aspirin and NSAIDs can increase the risk of bleeding when taken with
warfarin due to antiplatelet effects. Acetaminophen is a safer alternative for pain,
though it should still be used with caution. The other statements indicate correct
understanding of warfarin precautions.
5. A patient with a diagnosis of chronic obstructive pulmonary disease (COPD) is
receiving oxygen at 2 L/min via nasal cannula. The patient’s oxygen saturation
drops from 93% to 88%. The nurse observes that the patient appears drowsy
pg. 2
, 3
and confused. What should the nurse do first?
A. Increase the oxygen flow rate to 4 L/min
B. Administer a bronchodilator nebulizer treatment
C. Reposition the patient and assess the airway
D. Call the healthcare provider immediately
: Correct Answer : C
Rationale: The first step is to assess the patient’s airway, breathing, and the
oxygen delivery system. Repositioning may improve ventilation, and assessing the
airway ensures it is patent. Increasing oxygen may be contraindicated in CO₂
retention; the provider should be notified after immediate assessment. The
drowsiness and confusion could signal hypercapnia or hypoxia—assessment
precedes intervention.
6. A patient is receiving total parenteral nutrition (TPN) via a central venous
catheter. The TPN solution runs out and a new bag is not immediately available.
Which action should the nurse take?
A. Discontinue the infusion and cap the line
B. Infuse 10% dextrose in water at the same rate until the new TPN is available
C. Flush the line with saline and wait
D. Hang an infusion of normal saline at a keep-open rate
: Correct Answer : B
Rationale: Abruptly discontinuing TPN can cause rebound hypoglycemia because
the high dextrose content stimulates endogenous insulin secretion. Infusing 10%
dextrose in water prevents hypoglycemia while waiting for the TPN. Saline alone
does not provide glucose. The central line should not be capped without an order.
7. The nurse is caring for a patient in the immediate postoperative period after a
thyroidectomy. Which assessment finding is the priority to report?
A. Pain at the incision site
B. Hoarseness of voice
C. Stridor and respiratory distress
D. Serosanguineous drainage on the dressing
pg. 3
Kaplan NCLEX-RN Question Trainer #1 | 50
Comprehensive Nursing Questions and Rationales
KAPLAN NCLEX-RN QUESTION TRAINER #1
50 Comprehensive Nursing Questions with Detailed Rationales
1. The nurse is caring for a patient who returned from a cardiac catheterization
via the right femoral artery. Which finding requires immediate intervention?
A. A small bruise at the puncture site
B. Pain rated 3 on a 0–10 scale at the site
C. A hard, expanding mass at the puncture site with ecchymosis
D. Dorsalis pedis pulse 2+ on the affected side
: Correct Answer : C
Rationale: A hard, expanding mass accompanied by ecchymosis indicates a
retroperitoneal or arterial bleed and possible pseudoaneurysm; this is a
life-threatening emergency requiring immediate pressure and surgical
notification. A small bruise and mild pain are expected. A dorsalis pedis pulse of
2+ is a normal finding. The priority is recognizing the expanding hematoma as a
sign of active bleeding.
2. The nurse is preparing to administer a unit of packed red blood cells to a
patient. Which action should the nurse take first?
A. Check the patient’s vital signs
B. Verify the blood product with another licensed nurse at the bedside
C. Initiate the infusion slowly
D. Pre-medicate with acetaminophen
: Correct Answer : B
Rationale: The first priority in blood administration is verification of the patient’s
identity and the blood product. Two licensed nurses must check the patient’s ID
band, blood bag label, and transfusion order at the bedside to prevent a
pg. 1
,2
hemolytic transfusion reaction. Vital signs are obtained before, during, and after
the infusion, but verification is the initial step. Pre-medication may be ordered
but is not the first action.
3. A patient is admitted with a diagnosis of right-sided heart failure. Which
assessment finding does the nurse expect?
A. Pulmonary crackles
B. Orthopnea
C. Jugular vein distention
D. Frothy sputum
: Correct Answer : C
Rationale: Right-sided heart failure causes systemic venous congestion, resulting
in jugular vein distention, hepatomegaly, ascites, and peripheral edema.
Left-sided failure causes pulmonary congestion, crackles, orthopnea, and frothy
sputum. Recognizing the difference guides monitoring and treatment.
4. The nurse is teaching a patient about a new prescription for warfarin. Which
statement by the patient indicates a need for further teaching?
A. “I will use an electric razor for shaving.”
B. “I will avoid eating large amounts of green leafy vegetables.”
C. “I will take aspirin for headaches if I need pain relief.”
D. “I will report any signs of bleeding, such as bruising or blood in my urine.”
: Correct Answer : C
Rationale: Aspirin and NSAIDs can increase the risk of bleeding when taken with
warfarin due to antiplatelet effects. Acetaminophen is a safer alternative for pain,
though it should still be used with caution. The other statements indicate correct
understanding of warfarin precautions.
5. A patient with a diagnosis of chronic obstructive pulmonary disease (COPD) is
receiving oxygen at 2 L/min via nasal cannula. The patient’s oxygen saturation
drops from 93% to 88%. The nurse observes that the patient appears drowsy
pg. 2
, 3
and confused. What should the nurse do first?
A. Increase the oxygen flow rate to 4 L/min
B. Administer a bronchodilator nebulizer treatment
C. Reposition the patient and assess the airway
D. Call the healthcare provider immediately
: Correct Answer : C
Rationale: The first step is to assess the patient’s airway, breathing, and the
oxygen delivery system. Repositioning may improve ventilation, and assessing the
airway ensures it is patent. Increasing oxygen may be contraindicated in CO₂
retention; the provider should be notified after immediate assessment. The
drowsiness and confusion could signal hypercapnia or hypoxia—assessment
precedes intervention.
6. A patient is receiving total parenteral nutrition (TPN) via a central venous
catheter. The TPN solution runs out and a new bag is not immediately available.
Which action should the nurse take?
A. Discontinue the infusion and cap the line
B. Infuse 10% dextrose in water at the same rate until the new TPN is available
C. Flush the line with saline and wait
D. Hang an infusion of normal saline at a keep-open rate
: Correct Answer : B
Rationale: Abruptly discontinuing TPN can cause rebound hypoglycemia because
the high dextrose content stimulates endogenous insulin secretion. Infusing 10%
dextrose in water prevents hypoglycemia while waiting for the TPN. Saline alone
does not provide glucose. The central line should not be capped without an order.
7. The nurse is caring for a patient in the immediate postoperative period after a
thyroidectomy. Which assessment finding is the priority to report?
A. Pain at the incision site
B. Hoarseness of voice
C. Stridor and respiratory distress
D. Serosanguineous drainage on the dressing
pg. 3
