1
Kaplan NCLEX-RN Sample Test #3 | 150 NGN
Nursing Questions with Rationales
SECTION 1 – MANAGEMENT OF CARE (Questions 1–15)
1. A nurse is triaging clients after a mass casualty incident. Which client should
receive priority care (red tag)?
A) Client with a simple fracture of the arm
B) Client with a minor laceration
C) Client with a tension pneumothorax
D) Client who is deceased
: Correct Answer : C
Rationale: Red tag (immediate) clients have life-threatening injuries that are
survivable with prompt intervention. A tension pneumothorax is a medical
emergency requiring immediate decompression. Minor injuries are green (minor)
or yellow (delayed). Deceased are black.
2. A nurse manager is discussing the use of restraint with staff. Which of the
following is an appropriate reason for applying restraints?
A) To prevent the client from removing a feeding tube
B) To punish a client for aggressive behavior
C) To prevent injury to the client or others
D) To replace close observation by staff
: Correct Answer : C
Rationale: Restraints may only be used to ensure the physical safety of the client
or others. They are not for punishment, staff convenience, or as a substitute for
adequate staffing.
3. A nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which
of the following tasks is appropriate to delegate?
A) Measure intake and output
B) Assess a client’s pain level
pg. 1
,2
C) Administer oral medications
D) Teach a client about insulin injection
: Correct Answer : A
Rationale: UAPs can measure and record intake and output, vital signs, and assist
with ADLs. Assessment, medication administration, and teaching require licensed
nursing judgment.
4. A nurse is caring for a client who has a do-not-resuscitate (DNR) order. The
client’s family requests that the DNR be rescinded. What is the nurse’s priority
action?
A) Notify the provider
B) Remove the DNR order from the chart
C) Follow the family’s wishes immediately
D) Contact the ethics committee
: Correct Answer : A
Rationale: The provider must be notified to discuss the request and, if
appropriate, write a new order. The nurse cannot unilaterally remove a DNR
order. The ethics committee may be consulted later.
5. A nurse is caring for a client who has a new diagnosis of terminal cancer. The
client states, “I don’t want any more treatment.” What is the nurse’s priority
response?
A) “You need to continue treatment to live longer.”
B) “Let me call your family to discuss this.”
C) “Tell me more about your concerns regarding treatment.”
D) “You should speak with your doctor about stopping treatment.”
: Correct Answer : C
Rationale: The nurse should explore the client’s concerns and values. The client
has the right to refuse treatment. The nurse should facilitate communication with
the healthcare team.
6. A nurse is preparing to discharge a client who has a new colostomy. Which of
the following referrals is most appropriate?
pg. 2
,3
A) Physical therapy
B) Wound, ostomy, and continence nurse (WOCN)
C) Occupational therapy
D) Speech therapy
: Correct Answer : B
Rationale: A WOCN is specially trained in ostomy care and can provide education,
support, and follow-up. Physical and occupational therapy are not indicated
unless there are mobility issues.
7. A nurse is caring for a client who is being transferred to another unit. Which
of the following should the nurse include in the hand-off report?
A) Current medications and treatments
B) The client’s family medical history
C) The client’s insurance information
D) The client’s religious preferences
: Correct Answer : A
Rationale: Hand-off communication should include relevant clinical information:
diagnosis, current status, medications, treatments, and pending tests. Personal
and financial information is not part of clinical hand-off.
8. A nurse is planning care for a client who has a new prescription for restraints.
Which of the following is an appropriate action?
A) Obtain a provider’s order within 1-4 hours
B) Apply restraints for 4 hours then release for 30 minutes
C) Tie the restraints to the side rail of the bed
D) Document the client’s behavior every 4 hours
: Correct Answer : A
Rationale: A provider’s order must be obtained within 1-4 hours (depending on
facility policy). Restraints should be removed every 2 hours for range of motion,
toileting, and comfort. They should be tied to the bed frame, not side rails.
9. A nurse is caring for a client who has a living will. Which of the following
statements is true about a living will?
pg. 3
, 4
A) It appoints a healthcare proxy
B) It specifies the client’s wishes regarding life-sustaining treatment
C) It is legally binding only if the client is competent
D) It requires a new signature every year
: Correct Answer : B
Rationale: A living will is an advance directive that outlines the types of medical
treatments the client does or does not want at the end of life. A durable power of
attorney for health care appoints a proxy.
10. A nurse is admitting a client who speaks a different language. Which of the
following is the most appropriate action?
A) Use a family member as an interpreter
B) Obtain a trained medical interpreter
C) Speak loudly and slowly in English
D) Use written translated materials only
: Correct Answer : B
Rationale: A trained medical interpreter ensures accurate communication and
maintains confidentiality. Family members may not be qualified or may alter
information. Speaking loudly does not improve understanding.
11. A nurse is participating in a root cause analysis after a medication error.
Which of the following is the purpose of this process?
A) Identify system failures that contributed to the error
B) Assign blame to the individual nurse
C) Discipline the staff involved
D) Create a record for legal purposes
: Correct Answer : A
Rationale: Root cause analysis is a quality improvement process that identifies
underlying system issues (e.g., look-alike medications, distractions) to prevent
future errors. It is not punitive.
12. A nurse is caring for a client who is confused and trying to pull out their IV
line. Which of the following interventions should the nurse implement first?
pg. 4
Kaplan NCLEX-RN Sample Test #3 | 150 NGN
Nursing Questions with Rationales
SECTION 1 – MANAGEMENT OF CARE (Questions 1–15)
1. A nurse is triaging clients after a mass casualty incident. Which client should
receive priority care (red tag)?
A) Client with a simple fracture of the arm
B) Client with a minor laceration
C) Client with a tension pneumothorax
D) Client who is deceased
: Correct Answer : C
Rationale: Red tag (immediate) clients have life-threatening injuries that are
survivable with prompt intervention. A tension pneumothorax is a medical
emergency requiring immediate decompression. Minor injuries are green (minor)
or yellow (delayed). Deceased are black.
2. A nurse manager is discussing the use of restraint with staff. Which of the
following is an appropriate reason for applying restraints?
A) To prevent the client from removing a feeding tube
B) To punish a client for aggressive behavior
C) To prevent injury to the client or others
D) To replace close observation by staff
: Correct Answer : C
Rationale: Restraints may only be used to ensure the physical safety of the client
or others. They are not for punishment, staff convenience, or as a substitute for
adequate staffing.
3. A nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which
of the following tasks is appropriate to delegate?
A) Measure intake and output
B) Assess a client’s pain level
pg. 1
,2
C) Administer oral medications
D) Teach a client about insulin injection
: Correct Answer : A
Rationale: UAPs can measure and record intake and output, vital signs, and assist
with ADLs. Assessment, medication administration, and teaching require licensed
nursing judgment.
4. A nurse is caring for a client who has a do-not-resuscitate (DNR) order. The
client’s family requests that the DNR be rescinded. What is the nurse’s priority
action?
A) Notify the provider
B) Remove the DNR order from the chart
C) Follow the family’s wishes immediately
D) Contact the ethics committee
: Correct Answer : A
Rationale: The provider must be notified to discuss the request and, if
appropriate, write a new order. The nurse cannot unilaterally remove a DNR
order. The ethics committee may be consulted later.
5. A nurse is caring for a client who has a new diagnosis of terminal cancer. The
client states, “I don’t want any more treatment.” What is the nurse’s priority
response?
A) “You need to continue treatment to live longer.”
B) “Let me call your family to discuss this.”
C) “Tell me more about your concerns regarding treatment.”
D) “You should speak with your doctor about stopping treatment.”
: Correct Answer : C
Rationale: The nurse should explore the client’s concerns and values. The client
has the right to refuse treatment. The nurse should facilitate communication with
the healthcare team.
6. A nurse is preparing to discharge a client who has a new colostomy. Which of
the following referrals is most appropriate?
pg. 2
,3
A) Physical therapy
B) Wound, ostomy, and continence nurse (WOCN)
C) Occupational therapy
D) Speech therapy
: Correct Answer : B
Rationale: A WOCN is specially trained in ostomy care and can provide education,
support, and follow-up. Physical and occupational therapy are not indicated
unless there are mobility issues.
7. A nurse is caring for a client who is being transferred to another unit. Which
of the following should the nurse include in the hand-off report?
A) Current medications and treatments
B) The client’s family medical history
C) The client’s insurance information
D) The client’s religious preferences
: Correct Answer : A
Rationale: Hand-off communication should include relevant clinical information:
diagnosis, current status, medications, treatments, and pending tests. Personal
and financial information is not part of clinical hand-off.
8. A nurse is planning care for a client who has a new prescription for restraints.
Which of the following is an appropriate action?
A) Obtain a provider’s order within 1-4 hours
B) Apply restraints for 4 hours then release for 30 minutes
C) Tie the restraints to the side rail of the bed
D) Document the client’s behavior every 4 hours
: Correct Answer : A
Rationale: A provider’s order must be obtained within 1-4 hours (depending on
facility policy). Restraints should be removed every 2 hours for range of motion,
toileting, and comfort. They should be tied to the bed frame, not side rails.
9. A nurse is caring for a client who has a living will. Which of the following
statements is true about a living will?
pg. 3
, 4
A) It appoints a healthcare proxy
B) It specifies the client’s wishes regarding life-sustaining treatment
C) It is legally binding only if the client is competent
D) It requires a new signature every year
: Correct Answer : B
Rationale: A living will is an advance directive that outlines the types of medical
treatments the client does or does not want at the end of life. A durable power of
attorney for health care appoints a proxy.
10. A nurse is admitting a client who speaks a different language. Which of the
following is the most appropriate action?
A) Use a family member as an interpreter
B) Obtain a trained medical interpreter
C) Speak loudly and slowly in English
D) Use written translated materials only
: Correct Answer : B
Rationale: A trained medical interpreter ensures accurate communication and
maintains confidentiality. Family members may not be qualified or may alter
information. Speaking loudly does not improve understanding.
11. A nurse is participating in a root cause analysis after a medication error.
Which of the following is the purpose of this process?
A) Identify system failures that contributed to the error
B) Assign blame to the individual nurse
C) Discipline the staff involved
D) Create a record for legal purposes
: Correct Answer : A
Rationale: Root cause analysis is a quality improvement process that identifies
underlying system issues (e.g., look-alike medications, distractions) to prevent
future errors. It is not punitive.
12. A nurse is caring for a client who is confused and trying to pull out their IV
line. Which of the following interventions should the nurse implement first?
pg. 4
