KAPLAN MISSED QUESTIONS
(UPDATED 2025)VERIFIED BY EXPERT
(100% SATISFACTION
GUARANTEE)GRADED A+
The emergency management team notifies the ER department nurse to expect 50 victims in about 15
minutes. Which action does the nurse take first?
A. contacts the hospital supervisor
B. tell the emergency management team to reroute 25 victims
C. activates the hospital disaster plan
D. informs the emergency department that nurses must work overtime
A
follow chain of command
The nurse prepares to insert an IV in a client diagnosed with type 1 DM who reports extreme thirst,
frequent urination, and fruity-smelling breath. Which nursing action demonstrates appropriate
peripheral line placement? (SATA)
1. insert the IV catheter in one of the dorsal metacarpal veins
2. insert the IV catheter in the greater saphenous vein
3. place the IV catheter below the antecubital fossa
4. choose an IV site that is pulsatile on palpitation
5. gently insert the IV catheter at a 55-degree angle
1 - this client's symptoms are suggestive of diabetic ketoacidosis and indicate the need for rapid fluid
resuscitation to dilute blood glucose and treat dehydration. Inserting the IV catheter in a dorsal
metacarpal vein allows rapid fluid resuscitation because these veins are usually large and easy to find
3 - if using a brachial vein, the nurse should insert below or above the antecubital fossa to prevent the
IV catheter from being dislodged or kinked
A client returns from surgery after a total hip arthroplasty. The hip has a large surgical dressing and a
collapsible drainage device. Which finding two hours after surgery requires the nurse to call the health
care provider?
, A. a small amount of bloody drainage on the dressing
B. the client reports increased pain at the surgical site
C. a harsh, hollow sound is auscultated over the trachea
D. the client's BP is 136/86
C
increased pain indicates possible dislocation
The nurse provides care for a client who has a new prescription for an anticoagulant medication.
Which client statement indicates a further need for teaching?
A. I will take the medication at the same time each day
B. I will notify the HCP if my stools are black or tarry
C. I will call the HCP if I have increased bruising or bleeding
D. I will avoid taking any over-the-counter medications
D
not all over the counter drugs need to be avoided so this nurse should review which OTC medications
the client is taking to determine if there are any interactions with anticoagulants
The nurse provides care for a client following a scleral buckling. Which nursing action is most
important?
A. remove all reading material
B. assess for nausea and vomiting
C. assess the drainage from the affected eye
D. irrigate the affected eye every 3 hours
B
Nausea and vomiting increase intraocular pressure and could cause damage to the repaired area
How far away should O2 be kept from heat sources?
O2 should be 5 feet away from a heat source
A nurse receives change-of-shift report. Which client does the nurse see first?
A. a client diagnosed with COPD w/ a PaO2 of 70mm Hg
B. a client diagnosed with type 1 diabetes mellitus who was just informed the spouse was seriously
injured
C. a client scheduled to leave for the operating room in 30 minutes for a heart valve replacement
D. a client 10 hours postoperative after a right mastectomy and reporting wet sheets under the back
(UPDATED 2025)VERIFIED BY EXPERT
(100% SATISFACTION
GUARANTEE)GRADED A+
The emergency management team notifies the ER department nurse to expect 50 victims in about 15
minutes. Which action does the nurse take first?
A. contacts the hospital supervisor
B. tell the emergency management team to reroute 25 victims
C. activates the hospital disaster plan
D. informs the emergency department that nurses must work overtime
A
follow chain of command
The nurse prepares to insert an IV in a client diagnosed with type 1 DM who reports extreme thirst,
frequent urination, and fruity-smelling breath. Which nursing action demonstrates appropriate
peripheral line placement? (SATA)
1. insert the IV catheter in one of the dorsal metacarpal veins
2. insert the IV catheter in the greater saphenous vein
3. place the IV catheter below the antecubital fossa
4. choose an IV site that is pulsatile on palpitation
5. gently insert the IV catheter at a 55-degree angle
1 - this client's symptoms are suggestive of diabetic ketoacidosis and indicate the need for rapid fluid
resuscitation to dilute blood glucose and treat dehydration. Inserting the IV catheter in a dorsal
metacarpal vein allows rapid fluid resuscitation because these veins are usually large and easy to find
3 - if using a brachial vein, the nurse should insert below or above the antecubital fossa to prevent the
IV catheter from being dislodged or kinked
A client returns from surgery after a total hip arthroplasty. The hip has a large surgical dressing and a
collapsible drainage device. Which finding two hours after surgery requires the nurse to call the health
care provider?
, A. a small amount of bloody drainage on the dressing
B. the client reports increased pain at the surgical site
C. a harsh, hollow sound is auscultated over the trachea
D. the client's BP is 136/86
C
increased pain indicates possible dislocation
The nurse provides care for a client who has a new prescription for an anticoagulant medication.
Which client statement indicates a further need for teaching?
A. I will take the medication at the same time each day
B. I will notify the HCP if my stools are black or tarry
C. I will call the HCP if I have increased bruising or bleeding
D. I will avoid taking any over-the-counter medications
D
not all over the counter drugs need to be avoided so this nurse should review which OTC medications
the client is taking to determine if there are any interactions with anticoagulants
The nurse provides care for a client following a scleral buckling. Which nursing action is most
important?
A. remove all reading material
B. assess for nausea and vomiting
C. assess the drainage from the affected eye
D. irrigate the affected eye every 3 hours
B
Nausea and vomiting increase intraocular pressure and could cause damage to the repaired area
How far away should O2 be kept from heat sources?
O2 should be 5 feet away from a heat source
A nurse receives change-of-shift report. Which client does the nurse see first?
A. a client diagnosed with COPD w/ a PaO2 of 70mm Hg
B. a client diagnosed with type 1 diabetes mellitus who was just informed the spouse was seriously
injured
C. a client scheduled to leave for the operating room in 30 minutes for a heart valve replacement
D. a client 10 hours postoperative after a right mastectomy and reporting wet sheets under the back
