KAPLAN DIAGNOSTIC COMPLETE
EXAM PREPARATION QUESTIONS AND
ANSWERS
1. A nurse is caring for a client with a spinal cord injury at the T4 level. The client reports a
sudden, severe headache and is visibly flushed. The blood pressure is 190/100 mmHg. Which
action should the nurse take first?
A. Administer the prescribed PRN antihypertensive medication.
B. Place the client in a flat, supine position to stabilize the spine.
C. Check the client’s bladder for distention or a kinked catheter.
D. Perform a neurological assessment to check for increased intracranial pressure.
Answer: C
Conceptual Explanation: The client is exhibiting signs of autonomic dysreflexia, a medical
emergency. The first priority is to identify and remove the triggering stimulus, most
commonly a distended bladder or impacted bowel, while sitting the client up to lower
blood pressure.
,2. A client is admitted with Diabetic Ketoacidosis (DKA). The nurse notes a blood glucose of
550 mg/dL and the start of an insulin drip. Which laboratory value requires the most
immediate notification to the healthcare provider?
A. Serum sodium of 135 mEq/L.
B. Bicarbonate level of 12 mEq/L.
C. Potassium level of 3.2 mEq/L.
D. Blood Urea Nitrogen (BUN) of 28 mg/dL.
Answer: C
Conceptual Explanation: Insulin administration causes potassium to shift into the cells,
potentially worsening hypokalemia. A potassium level of 3.2 is dangerously low and must
be corrected before or during insulin therapy to prevent fatal arrhythmias.
3. The nurse is assessing a client four hours after a subtotal thyroidectomy. Which finding is
the most concerning and requires immediate intervention?
A. Laryngeal stridor heard on inspiration.
B. Hoarseness when the client speaks.
C. Pain at the surgical incision site.
D. Calcium level of 8.8 mg/dL.
Answer: A
, Conceptual Explanation: Laryngeal stridor is a sign of acute airway obstruction, which
can occur due to edema or nerve damage after thyroid surgery. This is a life-threatening
emergency.
4. A child is admitted with suspected epiglottitis. Which nursing action is contraindicated?
A. Setting up emergency intubation equipment at the bedside.
B. Maintaining the child in an upright, sitting position.
C. Assessing the throat with a tongue blade to visualize the epiglottis.
D. Administering humidified oxygen via a mask.
Answer: C
Conceptual Explanation: Using a tongue blade or performing a throat culture can trigger a
complete laryngospasm and airway obstruction in a child with epiglottitis.
5. Which client should the nurse assess first after receiving the change-of-shift report?
A. A client with pneumonia who has an oxygen saturation of 91% on room air.
B. A client who is 2 days post-op and has not yet had a bowel movement.
C. A client with a history of angina who reports indigestion-like chest pain.
D. A client with controlled diabetes who has a fasting blood sugar of 140 mg/dL.
Answer: C
EXAM PREPARATION QUESTIONS AND
ANSWERS
1. A nurse is caring for a client with a spinal cord injury at the T4 level. The client reports a
sudden, severe headache and is visibly flushed. The blood pressure is 190/100 mmHg. Which
action should the nurse take first?
A. Administer the prescribed PRN antihypertensive medication.
B. Place the client in a flat, supine position to stabilize the spine.
C. Check the client’s bladder for distention or a kinked catheter.
D. Perform a neurological assessment to check for increased intracranial pressure.
Answer: C
Conceptual Explanation: The client is exhibiting signs of autonomic dysreflexia, a medical
emergency. The first priority is to identify and remove the triggering stimulus, most
commonly a distended bladder or impacted bowel, while sitting the client up to lower
blood pressure.
,2. A client is admitted with Diabetic Ketoacidosis (DKA). The nurse notes a blood glucose of
550 mg/dL and the start of an insulin drip. Which laboratory value requires the most
immediate notification to the healthcare provider?
A. Serum sodium of 135 mEq/L.
B. Bicarbonate level of 12 mEq/L.
C. Potassium level of 3.2 mEq/L.
D. Blood Urea Nitrogen (BUN) of 28 mg/dL.
Answer: C
Conceptual Explanation: Insulin administration causes potassium to shift into the cells,
potentially worsening hypokalemia. A potassium level of 3.2 is dangerously low and must
be corrected before or during insulin therapy to prevent fatal arrhythmias.
3. The nurse is assessing a client four hours after a subtotal thyroidectomy. Which finding is
the most concerning and requires immediate intervention?
A. Laryngeal stridor heard on inspiration.
B. Hoarseness when the client speaks.
C. Pain at the surgical incision site.
D. Calcium level of 8.8 mg/dL.
Answer: A
, Conceptual Explanation: Laryngeal stridor is a sign of acute airway obstruction, which
can occur due to edema or nerve damage after thyroid surgery. This is a life-threatening
emergency.
4. A child is admitted with suspected epiglottitis. Which nursing action is contraindicated?
A. Setting up emergency intubation equipment at the bedside.
B. Maintaining the child in an upright, sitting position.
C. Assessing the throat with a tongue blade to visualize the epiglottis.
D. Administering humidified oxygen via a mask.
Answer: C
Conceptual Explanation: Using a tongue blade or performing a throat culture can trigger a
complete laryngospasm and airway obstruction in a child with epiglottitis.
5. Which client should the nurse assess first after receiving the change-of-shift report?
A. A client with pneumonia who has an oxygen saturation of 91% on room air.
B. A client who is 2 days post-op and has not yet had a bowel movement.
C. A client with a history of angina who reports indigestion-like chest pain.
D. A client with controlled diabetes who has a fasting blood sugar of 140 mg/dL.
Answer: C
