1
Kaplan NCLEX-RN Question Trainer #3 | 50 Board-Style
Questions and Rationales
Section 1: Safe and Effective Care Environment - Management of Care
(Questions 1-10)
1. The nurse is caring for a client who is receiving a blood transfusion. The client
develops sudden onset of chills, fever, flank pain, and hemoglobinuria 30
minutes after the transfusion was initiated. Place the following nursing actions
in the correct order of priority.
A. Notify the health care provider and blood bank
B. Stop the blood transfusion immediately
C. Send the blood bag, tubing, and a fresh urine specimen to the laboratory
D. Maintain IV access with 0.9% normal saline using new tubing
E. Monitor vital signs every 15 minutes and assess for signs of shock
Correct Order: B, D, E, A, C
RATIONALE: This client is experiencing an acute hemolytic transfusion reaction,
most likely due to ABO incompatibility. The priority sequence follows the nursing
process and ABC framework:
1. STOP the transfusion immediately - this is the most critical action to
prevent further infusion of incompatible blood.
2. Maintain IV access with 0.9% normal saline through NEW tubing - this
prevents additional incompatible blood from entering the client and
maintains vascular access for emergency medications.
3. Monitor vital signs and assess for shock - the nurse must assess the client's
current status and ongoing response.
4. Notify the provider and blood bank - communication is essential but follows
immediate client safety interventions.
pg. 1
,2
5. Send blood bag, tubing, and specimens to the lab - this is necessary for
investigation but is the lowest priority after client stabilization.
2. The nurse is delegating tasks to the unlicensed assistive personnel (UAP).
Which task is appropriate to delegate to the UAP?
A. Teaching a client with newly diagnosed diabetes how to perform blood glucose
monitoring
B. Performing a sterile dressing change on a client with a central venous catheter
C. Obtaining a routine urine specimen from a client and transporting it to the
laboratory
D. Assessing a client's lung sounds following a thoracentesis
RATIONALE: The nurse may delegate routine, non-invasive tasks to UAP if they do
not require nursing judgment, assessment, or teaching. Obtaining a routine urine
specimen (following established protocol) and transporting it to the lab is a
standardized task that does not require clinical judgment and is within the UAP's
scope of practice.
• A: Teaching blood glucose monitoring - Incorrect. Teaching requires
assessment of learning needs, evaluation of understanding, and
professional nursing judgment. Teaching cannot be delegated to UAP.
• B: Sterile dressing change - Incorrect. Central line dressing changes require
sterile technique and assessment of the insertion site for signs of infection.
This is a nursing procedure that cannot be delegated to UAP.
• D: Assessing lung sounds - Incorrect. Assessment is a core nursing function
that requires clinical judgment and cannot be delegated to UAP.
3. The nurse is caring for a client who had a total knee arthroplasty 6 hours ago.
The client has a continuous passive motion (CPM) machine ordered. The UAP
reports that the client is rating pain as 8 out of 10. Which action should the
nurse take FIRST?
A. Administer the prescribed PRN oxycodone 5 mg PO
B. Assess the client's surgical site, vital signs, and neurovascular status
C. Instruct the UAP to stop the CPM machine and reposition the client
D. Notify the health care provider of the client's pain level
pg. 2
,3
RATIONALE: The nurse must first ASSESS the client before implementing any
interventions. The nursing process (Assessment, Diagnosis, Planning,
Implementation, Evaluation) requires that assessment data be collected before
interventions are implemented. The nurse needs to evaluate the surgical site for
signs of compartment syndrome, infection, or excessive swelling, assess
neurovascular status (6 P's), and take vital signs to rule out complications before
administering pain medication.
• A: Administer oxycodone - Incorrect. Pain medication should not be
administered before the nurse assesses the cause and nature of the pain.
The pain could be a sign of a complication (compartment syndrome,
neurovascular compromise).
• C: Instruct UAP to stop CPM - Incorrect. While the UAP may stop the CPM,
this does not address the need for nursing assessment. The nurse must first
assess.
• D: Notify the provider - Incorrect. The nurse must have a complete
assessment to report to the provider, including pain characteristics, surgical
site appearance, and neurovascular status.
4. The nurse is assigned to care for four clients. Which client should the nurse
assess FIRST?
A. A client 2 days post-operative after an abdominal hysterectomy who has
serosanguineous drainage on the abdominal dressing
B. A client with pneumonia who has a productive cough with green sputum and a
temperature of 100.4°F (38°C)
C. A client with a chest tube who has continuous bubbling in the water-seal
chamber and is reporting new-onset shortness of breath
D. A client with diabetes who has a capillary blood glucose of 180 mg/dL before
breakfast
RATIONALE: Continuous bubbling in the water-seal chamber indicates an air leak.
When this is accompanied by new-onset shortness of breath, it suggests that the
air leak may be from the client's lung (bronchopleural fistula) and that the
pneumothorax may be worsening or the lung is not re-expanding. This client is at
highest risk for respiratory compromise and requires immediate assessment.
pg. 3
, 4
• A: Post-hysterectomy with serosanguineous drainage - Incorrect.
Serosanguineous drainage (pink-tinged, serous/blood mixture) on post-
operative day 2 is an expected finding and does not indicate an emergency.
• B: Pneumonia with productive cough and low-grade fever - Incorrect.
These are expected clinical manifestations of pneumonia. The client is
stable and does not require immediate assessment.
• D: Diabetes with glucose 180 mg/dL - Incorrect. While elevated, a fasting
glucose of 180 mg/dL is not immediately life-threatening. It requires
intervention but is not the priority.
5. The charge nurse is making assignments for the oncoming shift. Which
assignment is MOST appropriate?
A. Assign the new graduate nurse to a client with a new tracheostomy requiring
frequent suctioning
B. Assign the experienced nurse to a client with multiple trauma injuries requiring
hourly neuro checks and multiple IV medications
C. Assign the licensed practical/vocational nurse (LPN/LVN) to initiate the
admission assessment on a newly admitted client
D. Assign the UAP to administer a tube feeding to a client with a gastrostomy tube
RATIONALE: The experienced nurse should be assigned to the most complex,
unstable clients. A client with multiple trauma requiring hourly neurologic
assessments (GCS, pupil checks, motor/sensory) and multiple IV medications
(vasoactive drips, sedation, antibiotics) is highly complex and requires the critical
thinking and clinical judgment of an experienced registered nurse.
• A: New graduate to new tracheostomy - Incorrect. A new tracheostomy
requires frequent assessment, suctioning, and care that should be assigned
to a more experienced nurse. The new graduate may need additional
support.
• C: LPN/LVN to initiate admission assessment - Incorrect. The initial
admission assessment must be performed by a registered nurse. LPNs/LVNs
may collect data but cannot initiate the comprehensive assessment.
• D: UAP to administer tube feeding - Incorrect. Administration of enteral
nutrition is a nursing function that requires assessment of tube placement,
pg. 4
Kaplan NCLEX-RN Question Trainer #3 | 50 Board-Style
Questions and Rationales
Section 1: Safe and Effective Care Environment - Management of Care
(Questions 1-10)
1. The nurse is caring for a client who is receiving a blood transfusion. The client
develops sudden onset of chills, fever, flank pain, and hemoglobinuria 30
minutes after the transfusion was initiated. Place the following nursing actions
in the correct order of priority.
A. Notify the health care provider and blood bank
B. Stop the blood transfusion immediately
C. Send the blood bag, tubing, and a fresh urine specimen to the laboratory
D. Maintain IV access with 0.9% normal saline using new tubing
E. Monitor vital signs every 15 minutes and assess for signs of shock
Correct Order: B, D, E, A, C
RATIONALE: This client is experiencing an acute hemolytic transfusion reaction,
most likely due to ABO incompatibility. The priority sequence follows the nursing
process and ABC framework:
1. STOP the transfusion immediately - this is the most critical action to
prevent further infusion of incompatible blood.
2. Maintain IV access with 0.9% normal saline through NEW tubing - this
prevents additional incompatible blood from entering the client and
maintains vascular access for emergency medications.
3. Monitor vital signs and assess for shock - the nurse must assess the client's
current status and ongoing response.
4. Notify the provider and blood bank - communication is essential but follows
immediate client safety interventions.
pg. 1
,2
5. Send blood bag, tubing, and specimens to the lab - this is necessary for
investigation but is the lowest priority after client stabilization.
2. The nurse is delegating tasks to the unlicensed assistive personnel (UAP).
Which task is appropriate to delegate to the UAP?
A. Teaching a client with newly diagnosed diabetes how to perform blood glucose
monitoring
B. Performing a sterile dressing change on a client with a central venous catheter
C. Obtaining a routine urine specimen from a client and transporting it to the
laboratory
D. Assessing a client's lung sounds following a thoracentesis
RATIONALE: The nurse may delegate routine, non-invasive tasks to UAP if they do
not require nursing judgment, assessment, or teaching. Obtaining a routine urine
specimen (following established protocol) and transporting it to the lab is a
standardized task that does not require clinical judgment and is within the UAP's
scope of practice.
• A: Teaching blood glucose monitoring - Incorrect. Teaching requires
assessment of learning needs, evaluation of understanding, and
professional nursing judgment. Teaching cannot be delegated to UAP.
• B: Sterile dressing change - Incorrect. Central line dressing changes require
sterile technique and assessment of the insertion site for signs of infection.
This is a nursing procedure that cannot be delegated to UAP.
• D: Assessing lung sounds - Incorrect. Assessment is a core nursing function
that requires clinical judgment and cannot be delegated to UAP.
3. The nurse is caring for a client who had a total knee arthroplasty 6 hours ago.
The client has a continuous passive motion (CPM) machine ordered. The UAP
reports that the client is rating pain as 8 out of 10. Which action should the
nurse take FIRST?
A. Administer the prescribed PRN oxycodone 5 mg PO
B. Assess the client's surgical site, vital signs, and neurovascular status
C. Instruct the UAP to stop the CPM machine and reposition the client
D. Notify the health care provider of the client's pain level
pg. 2
,3
RATIONALE: The nurse must first ASSESS the client before implementing any
interventions. The nursing process (Assessment, Diagnosis, Planning,
Implementation, Evaluation) requires that assessment data be collected before
interventions are implemented. The nurse needs to evaluate the surgical site for
signs of compartment syndrome, infection, or excessive swelling, assess
neurovascular status (6 P's), and take vital signs to rule out complications before
administering pain medication.
• A: Administer oxycodone - Incorrect. Pain medication should not be
administered before the nurse assesses the cause and nature of the pain.
The pain could be a sign of a complication (compartment syndrome,
neurovascular compromise).
• C: Instruct UAP to stop CPM - Incorrect. While the UAP may stop the CPM,
this does not address the need for nursing assessment. The nurse must first
assess.
• D: Notify the provider - Incorrect. The nurse must have a complete
assessment to report to the provider, including pain characteristics, surgical
site appearance, and neurovascular status.
4. The nurse is assigned to care for four clients. Which client should the nurse
assess FIRST?
A. A client 2 days post-operative after an abdominal hysterectomy who has
serosanguineous drainage on the abdominal dressing
B. A client with pneumonia who has a productive cough with green sputum and a
temperature of 100.4°F (38°C)
C. A client with a chest tube who has continuous bubbling in the water-seal
chamber and is reporting new-onset shortness of breath
D. A client with diabetes who has a capillary blood glucose of 180 mg/dL before
breakfast
RATIONALE: Continuous bubbling in the water-seal chamber indicates an air leak.
When this is accompanied by new-onset shortness of breath, it suggests that the
air leak may be from the client's lung (bronchopleural fistula) and that the
pneumothorax may be worsening or the lung is not re-expanding. This client is at
highest risk for respiratory compromise and requires immediate assessment.
pg. 3
, 4
• A: Post-hysterectomy with serosanguineous drainage - Incorrect.
Serosanguineous drainage (pink-tinged, serous/blood mixture) on post-
operative day 2 is an expected finding and does not indicate an emergency.
• B: Pneumonia with productive cough and low-grade fever - Incorrect.
These are expected clinical manifestations of pneumonia. The client is
stable and does not require immediate assessment.
• D: Diabetes with glucose 180 mg/dL - Incorrect. While elevated, a fasting
glucose of 180 mg/dL is not immediately life-threatening. It requires
intervention but is not the priority.
5. The charge nurse is making assignments for the oncoming shift. Which
assignment is MOST appropriate?
A. Assign the new graduate nurse to a client with a new tracheostomy requiring
frequent suctioning
B. Assign the experienced nurse to a client with multiple trauma injuries requiring
hourly neuro checks and multiple IV medications
C. Assign the licensed practical/vocational nurse (LPN/LVN) to initiate the
admission assessment on a newly admitted client
D. Assign the UAP to administer a tube feeding to a client with a gastrostomy tube
RATIONALE: The experienced nurse should be assigned to the most complex,
unstable clients. A client with multiple trauma requiring hourly neurologic
assessments (GCS, pupil checks, motor/sensory) and multiple IV medications
(vasoactive drips, sedation, antibiotics) is highly complex and requires the critical
thinking and clinical judgment of an experienced registered nurse.
• A: New graduate to new tracheostomy - Incorrect. A new tracheostomy
requires frequent assessment, suctioning, and care that should be assigned
to a more experienced nurse. The new graduate may need additional
support.
• C: LPN/LVN to initiate admission assessment - Incorrect. The initial
admission assessment must be performed by a registered nurse. LPNs/LVNs
may collect data but cannot initiate the comprehensive assessment.
• D: UAP to administer tube feeding - Incorrect. Administration of enteral
nutrition is a nursing function that requires assessment of tube placement,
pg. 4
