KAPLAN NCLEX-RN TRAINER 4 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) PLUS RATIONALES 2026 Q&A
|LATEST EXAM UPDATE 2026/2027..
*Core Domains*
*Management of Care*
*Safety and Infection Control*
*Health Promotion and Maintenance*
*Psychosocial Integrity*
*Basic Care and Comfort*
*Pharmacological and Parenteral Therapies*
*Reduction of Risk Potential*
*Physiological Adaptation*
*Introduction*
*This comprehensive assessment is designed to simulate the rigorous environment of the professional nursing licensure examinati
SECTION ONE: QUESTIONS 1–100
A nurse is caring for a client with a suspected diagnosis of pulmonary embolism. Which assessment finding is most important for the
nurse to report to the provider immediately?
A. Pleuritic chest pain
B. Sudden onset of dyspnea
C. Tachycardia and diaphoresis
D. Change in level of consciousness
🟢D
🔴 RATIONALE: While pleuritic pain, dyspnea, and tachycardia are classic signs of pulmonary embolism, a change in level of
consciousness indicates severe hypoxia and potential brain injury, representing the most urgent threat to the client's life.
,A client is receiving an intravenous infusion of potassium chloride. The nurse notes the IV site is swollen, cool to the touch, and pale.
What is the nurse's priority action?
A. Elevate the extremity
B. Apply a warm compress
C. Stop the infusion and remove the catheter
D. Slow the infusion rate
🟢C
🔴 RATIONALE: The signs indicate infiltration. Because potassium chloride is a vesicant that can cause tissue necrosis, the infusion
must be stopped immediately and the catheter removed to prevent further tissue damage.
A nurse is prioritizing care for four clients. Which client should the nurse assess first?
A. A client with type 2 diabetes who has a blood glucose of 140 mg/dL
B. A client with chronic obstructive pulmonary disease who has an oxygen saturation of 90%
C. A client who is postoperative following an appendectomy and is reporting 6/10 pain
D. A client with a stage 2 pressure ulcer who requires a dressing change
🟢B
🔴 RATIONALE: An oxygen saturation of 90% in a COPD client is generally acceptable, but if it represents a sudden drop or is
accompanied by respiratory distress, it requires immediate assessment to rule out acute compromise compared to the other stable
clients.
An adolescent client is admitted with anorexia nervosa. Which nursing intervention is most appropriate during the initial phase of care?
A. Discuss the long-term physical effects of starvation
B. Encourage the client to choose their own meal plan
C. Monitor the client for one hour after meals
D. Provide strict caloric counts at every meal
🟢C
🔴 RATIONALE: Clients with anorexia nervosa may engage in purging behaviors or hiding food. Direct observation for at least one
hour after meals is essential to ensure nutritional intake and prevent compensatory behaviors.
A nurse is preparing to administer medications. Which medication order requires clarification by the nurse?
A. Digoxin 0.125 mg PO daily
B. Furosemide 40 mg IV push
C. Morphine sulfate 10 mg IM PRN for pain
D. Potassium chloride 10 mEq IV push
🟢D
, 🔴 RATIONALE: Potassium chloride should never be administered via IV push as it can cause fatal cardiac arrhythmias. It must
always be diluted and administered via an infusion pump.
A nurse is caring for a client with a chest tube. The nurse notes continuous bubbling in the water seal chamber. What does this
indicate?
A. Normal lung re-expansion
B. An air leak in the system
C. The suction control is set too high
D. A kink in the drainage tubing
🟢B
🔴 RATIONALE: Continuous bubbling in the water seal chamber is abnormal and indicates a leak in the chest tube system between
the client and the drainage device.
An elderly client is at risk for falls. Which intervention should the nurse include in the plan of care?
A. Keep the bed in the highest position
B. Place the client in a room far from the nurses' station
C. Keep the call light within reach at all times
D. Use physical restraints at night to prevent wandering
🟢C
🔴 RATIONALE: Maintaining the call light within reach is a standard safety measure that empowers the client to request assistance,
significantly reducing the risk of falls.
A client is diagnosed with hyperthyroidism. Which clinical manifestation should the nurse expect to observe?
A. Weight gain
B. Heat intolerance
C. Bradycardia
D. Constipation
🟢B
🔴 RATIONALE: Hyperthyroidism causes an increase in metabolic rate, leading to heat intolerance, weight loss, tachycardia, and
increased bowel motility.
A nurse is teaching a client about the administration of sublingual nitroglycerin. Which statement indicates the need for further
teaching?
A. I will place the tablet under my tongue when I have chest pain
B. I can take up to three tablets, five minutes apart
C. I will store the medication in a clear plastic container
D. I will sit down before taking the medication
|LATEST EXAM UPDATE 2026/2027..
*Core Domains*
*Management of Care*
*Safety and Infection Control*
*Health Promotion and Maintenance*
*Psychosocial Integrity*
*Basic Care and Comfort*
*Pharmacological and Parenteral Therapies*
*Reduction of Risk Potential*
*Physiological Adaptation*
*Introduction*
*This comprehensive assessment is designed to simulate the rigorous environment of the professional nursing licensure examinati
SECTION ONE: QUESTIONS 1–100
A nurse is caring for a client with a suspected diagnosis of pulmonary embolism. Which assessment finding is most important for the
nurse to report to the provider immediately?
A. Pleuritic chest pain
B. Sudden onset of dyspnea
C. Tachycardia and diaphoresis
D. Change in level of consciousness
🟢D
🔴 RATIONALE: While pleuritic pain, dyspnea, and tachycardia are classic signs of pulmonary embolism, a change in level of
consciousness indicates severe hypoxia and potential brain injury, representing the most urgent threat to the client's life.
,A client is receiving an intravenous infusion of potassium chloride. The nurse notes the IV site is swollen, cool to the touch, and pale.
What is the nurse's priority action?
A. Elevate the extremity
B. Apply a warm compress
C. Stop the infusion and remove the catheter
D. Slow the infusion rate
🟢C
🔴 RATIONALE: The signs indicate infiltration. Because potassium chloride is a vesicant that can cause tissue necrosis, the infusion
must be stopped immediately and the catheter removed to prevent further tissue damage.
A nurse is prioritizing care for four clients. Which client should the nurse assess first?
A. A client with type 2 diabetes who has a blood glucose of 140 mg/dL
B. A client with chronic obstructive pulmonary disease who has an oxygen saturation of 90%
C. A client who is postoperative following an appendectomy and is reporting 6/10 pain
D. A client with a stage 2 pressure ulcer who requires a dressing change
🟢B
🔴 RATIONALE: An oxygen saturation of 90% in a COPD client is generally acceptable, but if it represents a sudden drop or is
accompanied by respiratory distress, it requires immediate assessment to rule out acute compromise compared to the other stable
clients.
An adolescent client is admitted with anorexia nervosa. Which nursing intervention is most appropriate during the initial phase of care?
A. Discuss the long-term physical effects of starvation
B. Encourage the client to choose their own meal plan
C. Monitor the client for one hour after meals
D. Provide strict caloric counts at every meal
🟢C
🔴 RATIONALE: Clients with anorexia nervosa may engage in purging behaviors or hiding food. Direct observation for at least one
hour after meals is essential to ensure nutritional intake and prevent compensatory behaviors.
A nurse is preparing to administer medications. Which medication order requires clarification by the nurse?
A. Digoxin 0.125 mg PO daily
B. Furosemide 40 mg IV push
C. Morphine sulfate 10 mg IM PRN for pain
D. Potassium chloride 10 mEq IV push
🟢D
, 🔴 RATIONALE: Potassium chloride should never be administered via IV push as it can cause fatal cardiac arrhythmias. It must
always be diluted and administered via an infusion pump.
A nurse is caring for a client with a chest tube. The nurse notes continuous bubbling in the water seal chamber. What does this
indicate?
A. Normal lung re-expansion
B. An air leak in the system
C. The suction control is set too high
D. A kink in the drainage tubing
🟢B
🔴 RATIONALE: Continuous bubbling in the water seal chamber is abnormal and indicates a leak in the chest tube system between
the client and the drainage device.
An elderly client is at risk for falls. Which intervention should the nurse include in the plan of care?
A. Keep the bed in the highest position
B. Place the client in a room far from the nurses' station
C. Keep the call light within reach at all times
D. Use physical restraints at night to prevent wandering
🟢C
🔴 RATIONALE: Maintaining the call light within reach is a standard safety measure that empowers the client to request assistance,
significantly reducing the risk of falls.
A client is diagnosed with hyperthyroidism. Which clinical manifestation should the nurse expect to observe?
A. Weight gain
B. Heat intolerance
C. Bradycardia
D. Constipation
🟢B
🔴 RATIONALE: Hyperthyroidism causes an increase in metabolic rate, leading to heat intolerance, weight loss, tachycardia, and
increased bowel motility.
A nurse is teaching a client about the administration of sublingual nitroglycerin. Which statement indicates the need for further
teaching?
A. I will place the tablet under my tongue when I have chest pain
B. I can take up to three tablets, five minutes apart
C. I will store the medication in a clear plastic container
D. I will sit down before taking the medication
