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Kaplan NCLEX-RN Sample Test #1 | 150 Practice
Questions and Rationales
SAFE AND EFFECTIVE CARE ENVIRONMENT (1–20)
1. The nurse is caring for a client who is receiving a continuous IV infusion of
heparin. The morning aPTT result is 120 seconds (therapeutic range 46–70
seconds). Which is the priority nursing action?
A. Increase the heparin infusion rate
B. Continue the infusion at the current rate
C. Stop the heparin infusion and notify the healthcare provider
D. Administer protamine sulfate immediately
: Correct Answer : C
Rationale: An aPTT of 120 seconds is critically high, indicating a significant risk for
spontaneous bleeding. The infusion must be stopped immediately to prevent
further anticoagulation, and the provider must be notified for dose adjustment
(likely a hold and restart at a lower rate). Protamine sulfate (D) is used for severe
bleeding or very high overdose, not as a first-line response to a supratherapeutic
level without bleeding.
2. The nurse is preparing to administer a blood transfusion. The client states, “I
had a transfusion a few years ago and my throat got tight.” Which action should
the nurse take first?
A. Reassure the client that this is a common reaction
B. Obtain a set of vital signs and start the transfusion
C. Notify the healthcare provider and blood bank; obtain a detailed history of the
previous reaction
D. Pre-medicate with diphenhydramine and continue
: Correct Answer : C
Rationale: A history of tight throat during a previous transfusion suggests a
possible allergic or anaphylactic reaction. The nurse must investigate the prior
reaction fully and communicate with the provider and blood bank before
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proceeding. Pre-medication (D) may be ordered, but the safety of proceeding
must be determined first. The transfusion should not be started (B) without
further evaluation.
3. The nurse is delegating care for a group of clients to an unlicensed assistive
personnel (UAP). Which task is appropriate for the UAP?
A. Ambulating a client who had a total hip replacement 4 hours ago
B. Assessing the color and temperature of a client's foot in a new cast
C. Measuring and recording intake and output for a client with heart failure
D. Administering an enema to a client with a suspected bowel obstruction
: Correct Answer : C
Rationale: Measuring and recording intake and output is a data collection task
that can be delegated to a UAP, though the nurse must interpret the data.
Ambulating a fresh post-operative total hip client (A) requires assessment of
stability and knowledge of hip precautions—this is nursing responsibility.
Assessment (B) cannot be delegated. Administering an enema to a client with a
possible obstruction (D) requires nursing judgment and is contraindicated.
4. The charge nurse is making assignments for the upcoming shift. Which client
should be assigned to the most experienced RN?
A. A 32-year-old with acute pyelonephritis who is febrile and receiving IV
antibiotics
B. A 60-year-old with chronic obstructive pulmonary disease who is
oxygen-dependent and stable
C. A 40-year-old one day after a laparoscopic cholecystectomy, ready for
discharge
D. A 70-year-old with a bowel resection 24 hours ago whose blood pressure has
dropped from 128/72 to 94/58 and heart rate increased from 80 to 112
: Correct Answer : D
Rationale: The client in option D is demonstrating signs of hypovolemic shock
(tachycardia, hypotension) post-operatively, indicating possible internal
hemorrhage. This client requires frequent, skilled assessment and rapid
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intervention, making the most experienced nurse the best choice. The other
clients are stable or improving.
5. The nurse is preparing a sterile field. The nurse places a sterile item on the
field, and the outer edge of the package touches the 1-inch (2.5 cm) border of
the field. Which action should the nurse take?
A. Continue with the procedure; the border is considered sterile
B. Consider the field contaminated and set up a new sterile field
C. Move the item to the center of the field and continue
D. Remove the contaminated item and replace it with a new one
: Correct Answer : B
Rationale: A 1-inch (2.5 cm) border around the edge of a sterile drape is
considered non-sterile. Any item that touches this border is contaminated. The
entire field must be considered contaminated and a new sterile field created.
6. A fire breaks out in a trash can in a client's room. The nurse's first action is to:
A. Activate the fire alarm
B. Rescue the client and remove them from immediate danger
C. Contain the fire by closing the door
D. Extinguish the fire with a fire extinguisher
: Correct Answer : B
Rationale: The RACE mnemonic for fire safety: Rescue the client (remove them
from danger), Alarm (activate the fire alarm), Contain (close doors), Extinguish
(attempt to extinguish if safe). The priority is always client safety, so Rescue is
first.
7. The nurse is caring for a client with a central venous catheter. The insertion
site is red and tender, and the client has a temperature of 38.6°C (101.5°F). The
nurse should first:
A. Apply a warm compress to the site
B. Obtain blood cultures from the catheter and a peripheral site, then notify the
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provider
C. Change the dressing and apply antibiotic ointment
D. Remove the central catheter and send the tip for culture
: Correct Answer : B
Rationale: Signs of a central line-associated bloodstream infection (CLABSI)
include erythema, tenderness, and fever. The priority is to obtain cultures (both
from the catheter and a peripheral vein) before starting antibiotics, then notify
the provider for further management. Removal of the catheter (D) may be
ordered but is not the first independent nursing action unless specified by
protocol.
8. The nurse is caring for a client who has a new diagnosis of tuberculosis (TB)
and is placed on airborne precautions. Which personal protective equipment is
required when entering the client's room?
A. Surgical mask
B. N95 respirator
C. Gown and gloves only
D. Face shield and gown
: Correct Answer : B
Rationale: Airborne precautions for TB require an N95 respirator or powered
air-purifying respirator (PAPR). The room must have negative pressure airflow. A
surgical mask (A) is for droplet precautions. Gown and gloves are used as needed
but are not sufficient for airborne protection.
9. The nurse is receiving a telephone order from a healthcare provider. Which
action ensures safe communication?
A. Have the provider text the order to the unit
B. Transcribe the order directly onto the medication administration record
C. Write down the order, read it back to the provider, and obtain confirmation
D. Ask another nurse to listen to the order on speakerphone
: Correct Answer : C
Rationale: The Joint Commission requires that all telephone or verbal orders be
pg. 4
Kaplan NCLEX-RN Sample Test #1 | 150 Practice
Questions and Rationales
SAFE AND EFFECTIVE CARE ENVIRONMENT (1–20)
1. The nurse is caring for a client who is receiving a continuous IV infusion of
heparin. The morning aPTT result is 120 seconds (therapeutic range 46–70
seconds). Which is the priority nursing action?
A. Increase the heparin infusion rate
B. Continue the infusion at the current rate
C. Stop the heparin infusion and notify the healthcare provider
D. Administer protamine sulfate immediately
: Correct Answer : C
Rationale: An aPTT of 120 seconds is critically high, indicating a significant risk for
spontaneous bleeding. The infusion must be stopped immediately to prevent
further anticoagulation, and the provider must be notified for dose adjustment
(likely a hold and restart at a lower rate). Protamine sulfate (D) is used for severe
bleeding or very high overdose, not as a first-line response to a supratherapeutic
level without bleeding.
2. The nurse is preparing to administer a blood transfusion. The client states, “I
had a transfusion a few years ago and my throat got tight.” Which action should
the nurse take first?
A. Reassure the client that this is a common reaction
B. Obtain a set of vital signs and start the transfusion
C. Notify the healthcare provider and blood bank; obtain a detailed history of the
previous reaction
D. Pre-medicate with diphenhydramine and continue
: Correct Answer : C
Rationale: A history of tight throat during a previous transfusion suggests a
possible allergic or anaphylactic reaction. The nurse must investigate the prior
reaction fully and communicate with the provider and blood bank before
pg. 1
,2
proceeding. Pre-medication (D) may be ordered, but the safety of proceeding
must be determined first. The transfusion should not be started (B) without
further evaluation.
3. The nurse is delegating care for a group of clients to an unlicensed assistive
personnel (UAP). Which task is appropriate for the UAP?
A. Ambulating a client who had a total hip replacement 4 hours ago
B. Assessing the color and temperature of a client's foot in a new cast
C. Measuring and recording intake and output for a client with heart failure
D. Administering an enema to a client with a suspected bowel obstruction
: Correct Answer : C
Rationale: Measuring and recording intake and output is a data collection task
that can be delegated to a UAP, though the nurse must interpret the data.
Ambulating a fresh post-operative total hip client (A) requires assessment of
stability and knowledge of hip precautions—this is nursing responsibility.
Assessment (B) cannot be delegated. Administering an enema to a client with a
possible obstruction (D) requires nursing judgment and is contraindicated.
4. The charge nurse is making assignments for the upcoming shift. Which client
should be assigned to the most experienced RN?
A. A 32-year-old with acute pyelonephritis who is febrile and receiving IV
antibiotics
B. A 60-year-old with chronic obstructive pulmonary disease who is
oxygen-dependent and stable
C. A 40-year-old one day after a laparoscopic cholecystectomy, ready for
discharge
D. A 70-year-old with a bowel resection 24 hours ago whose blood pressure has
dropped from 128/72 to 94/58 and heart rate increased from 80 to 112
: Correct Answer : D
Rationale: The client in option D is demonstrating signs of hypovolemic shock
(tachycardia, hypotension) post-operatively, indicating possible internal
hemorrhage. This client requires frequent, skilled assessment and rapid
pg. 2
,3
intervention, making the most experienced nurse the best choice. The other
clients are stable or improving.
5. The nurse is preparing a sterile field. The nurse places a sterile item on the
field, and the outer edge of the package touches the 1-inch (2.5 cm) border of
the field. Which action should the nurse take?
A. Continue with the procedure; the border is considered sterile
B. Consider the field contaminated and set up a new sterile field
C. Move the item to the center of the field and continue
D. Remove the contaminated item and replace it with a new one
: Correct Answer : B
Rationale: A 1-inch (2.5 cm) border around the edge of a sterile drape is
considered non-sterile. Any item that touches this border is contaminated. The
entire field must be considered contaminated and a new sterile field created.
6. A fire breaks out in a trash can in a client's room. The nurse's first action is to:
A. Activate the fire alarm
B. Rescue the client and remove them from immediate danger
C. Contain the fire by closing the door
D. Extinguish the fire with a fire extinguisher
: Correct Answer : B
Rationale: The RACE mnemonic for fire safety: Rescue the client (remove them
from danger), Alarm (activate the fire alarm), Contain (close doors), Extinguish
(attempt to extinguish if safe). The priority is always client safety, so Rescue is
first.
7. The nurse is caring for a client with a central venous catheter. The insertion
site is red and tender, and the client has a temperature of 38.6°C (101.5°F). The
nurse should first:
A. Apply a warm compress to the site
B. Obtain blood cultures from the catheter and a peripheral site, then notify the
pg. 3
, 4
provider
C. Change the dressing and apply antibiotic ointment
D. Remove the central catheter and send the tip for culture
: Correct Answer : B
Rationale: Signs of a central line-associated bloodstream infection (CLABSI)
include erythema, tenderness, and fever. The priority is to obtain cultures (both
from the catheter and a peripheral vein) before starting antibiotics, then notify
the provider for further management. Removal of the catheter (D) may be
ordered but is not the first independent nursing action unless specified by
protocol.
8. The nurse is caring for a client who has a new diagnosis of tuberculosis (TB)
and is placed on airborne precautions. Which personal protective equipment is
required when entering the client's room?
A. Surgical mask
B. N95 respirator
C. Gown and gloves only
D. Face shield and gown
: Correct Answer : B
Rationale: Airborne precautions for TB require an N95 respirator or powered
air-purifying respirator (PAPR). The room must have negative pressure airflow. A
surgical mask (A) is for droplet precautions. Gown and gloves are used as needed
but are not sufficient for airborne protection.
9. The nurse is receiving a telephone order from a healthcare provider. Which
action ensures safe communication?
A. Have the provider text the order to the unit
B. Transcribe the order directly onto the medication administration record
C. Write down the order, read it back to the provider, and obtain confirmation
D. Ask another nurse to listen to the order on speakerphone
: Correct Answer : C
Rationale: The Joint Commission requires that all telephone or verbal orders be
pg. 4
