1
Kaplan NCLEX-RN CAT Exam #2 | 145 Adaptive NCLEX
Questions with Detailed Rationales
MANAGEMENT OF CARE & SAFETY (1–25)
1. The nurse is caring for a client 2 days after an exploratory laparotomy. The
client's wound is draining serosanguinous fluid, and the edges are pink, with a
small amount of granulation tissue. The nurse identifies this as which phase of
wound healing?
A. Hemostasis phase
B. Inflammatory phase
C. Proliferative phase
D. Maturation phase
: Correct Answer : C
Rationale: The proliferative (or fibroblastic) phase lasts from 3 to 24 days. Key
features include the formation of granulation tissue (pink/red and
cobblestone-like), collagen deposition, angiogenesis, and wound contraction.
Serosanguinous drainage is typical during this phase as new capillaries leak. The
inflammatory phase (B) is characterized by erythema, edema, and warmth in the
first 1–4 days. The maturation phase (D) involves scar remodeling and
strengthening over months to years.
2. The nurse is reviewing discharge instructions with a client who has a new
diagnosis of gastroesophageal reflux disease (GERD). Which statement by the
client indicates a need for further teaching?
A. "I will avoid lying down for at least 3 hours after eating."
B. "I should sleep with my head elevated on two pillows."
C. "I will eat small, frequent meals instead of three large meals."
D. "I can continue to drink a glass of red wine with dinner."
: Correct Answer : D
Rationale: Alcohol relaxes the lower esophageal sphincter (LES), increases gastric
acid secretion, and can directly irritate the esophageal mucosa, worsening GERD.
pg. 1
,2
Clients should be advised to avoid alcohol, caffeine, chocolate, peppermint, and
fatty/spicy foods. Sleeping with head elevated (B) reduces nocturnal reflux. Small,
frequent meals (C) decrease gastric distension and pressure.
3. The charge nurse is making assignments for the upcoming shift. Which client
should be assigned to the most experienced nurse?
A. A 24-year-old client with diabetic ketoacidosis on an insulin infusion whose last
blood glucose was 212 mg/dL
B. A 62-year-old client with a new diagnosis of lung cancer who is scheduled for a
biopsy in 2 hours
C. A 75-year-old client with a bowel resection 24 hours ago whose blood pressure
has dropped from 132/84 to 100/66 and heart rate increased from 78 to 104
D. A 40-year-old client with community-acquired pneumonia who is receiving IV
antibiotics and is ready for discharge planning
: Correct Answer : C
Rationale: The client in option C is exhibiting signs of hypovolemic shock or
internal hemorrhage (tachycardia and hypotension post-operatively). This client
requires frequent assessment and rapid intervention. The most experienced nurse
should manage a potentially unstable client. The DKA client (A) is improving. The
pre-op client (B) needs routine preparation. The pneumonia client (D) is stable
and nearing discharge.
4. The nurse is caring for a client with a central venous catheter. The insertion
site is red, tender, and the client has a temperature of 38.4°C (101.1°F). What is
the nurse's priority action?
A. Apply a warm compress to the insertion site
B. Notify the health care provider and prepare to change the catheter over a
guidewire
C. Draw blood cultures from the catheter and a peripheral site, then remove the
catheter
D. Administer the prescribed antipyretic and reassess in 30 minutes
pg. 2
,3
: Correct Answer : C
Rationale: The presentation suggests a central line-associated bloodstream
infection (CLABSI). The priority is to obtain cultures (both from the catheter hub
and a peripheral venipuncture) and then promptly remove the catheter when
infection is suspected. Administering an antipyretic (D) or applying a compress (A)
delays definitive treatment. Changing the catheter over a guidewire (B) is not
recommended when infection is suspected because it preserves the colonized
tract.
5. The nurse manager is evaluating a staff nurse's documentation. Which entry
best reflects appropriate documentation of an incident?
A. "Patient fell out of bed. Physician notified."
B. "Found patient on floor. Blood pressure stable. No injuries noted. Family
upset."
C. "Patient found lying on the floor beside the bed at 08:15. Denies pain. Full
range of motion in all extremities. Bedside rails were down. Provider notified at
08:20. Incident report filed."
D. "Error made in medication administration. Patient not harmed. Will monitor."
: Correct Answer : C
Rationale: Documentation of an incident should be factual, objective, and include
a description of the event, the patient's condition, interventions taken, and
notification of the provider. It should not include the word "error" (as that goes
on the incident report), assumptions, or opinions. The incident report itself is a
separate document and its existence is not mentioned in the medical record.
6. A client with terminal cancer tells the nurse, "I know I'm dying, but I just want
to see my daughter graduate next month." The nurse recognizes this statement
as an example of:
A. Denial
B. Anger
C. Bargaining
D. Acceptance
pg. 3
, 4
: Correct Answer : C
Rationale: Kübler-Ross's stages of grief include denial, anger, bargaining,
depression, and acceptance. The client is in the bargaining stage, making a deal
(to live until a specific event) in exchange for more time. The client acknowledges
the reality of death but is trying to postpone it. Denial (A) would involve refusing
to accept the diagnosis. Acceptance (D) is a state of peace.
7. The nurse is delegating tasks to the unlicensed assistive personnel (UAP).
Which task is appropriate for the UAP to perform?
A. Assess a client's breath sounds after a nebulizer treatment
B. Administer an enema to a client with a suspected bowel obstruction
C. Obtain vital signs on a client 1 hour after a blood transfusion was started
D. Ambulate a client who had a total hip replacement 12 hours ago
: Correct Answer : C
Rationale: Obtaining vital signs is within the UAP's scope for a stable client.
However, the nurse must interpret the data. Assessment (A) is a nursing function.
Administering an enema to a client with a suspected obstruction (B) is
contraindicated and requires nursing judgment. Ambulating a client post-hip
replacement (D) requires the nurse to assess the client's stability and need for
specific positioning/precautions, though in some facilities, UAPs ambulate stable
clients after initial nursing assessment. However, for the NCLEX, a task that
requires evaluation or assessment should not be delegated to a UAP. Option C
involves data collection (vital signs), which the UAP can perform and report to the
nurse.
8. A nurse is caring for a client who has a pulmonary artery catheter
(Swan-Ganz). The nurse notes a waveform that shifts from a clear pulmonary
artery tracing to a dampened, wedged tracing that remains even when the
balloon is deflated. The nurse should first:
A. Notify the provider immediately
B. Ask the client to cough forcefully
C. Attempt to aspirate blood from the distal port
D. Advance the catheter 1 cm
pg. 4
Kaplan NCLEX-RN CAT Exam #2 | 145 Adaptive NCLEX
Questions with Detailed Rationales
MANAGEMENT OF CARE & SAFETY (1–25)
1. The nurse is caring for a client 2 days after an exploratory laparotomy. The
client's wound is draining serosanguinous fluid, and the edges are pink, with a
small amount of granulation tissue. The nurse identifies this as which phase of
wound healing?
A. Hemostasis phase
B. Inflammatory phase
C. Proliferative phase
D. Maturation phase
: Correct Answer : C
Rationale: The proliferative (or fibroblastic) phase lasts from 3 to 24 days. Key
features include the formation of granulation tissue (pink/red and
cobblestone-like), collagen deposition, angiogenesis, and wound contraction.
Serosanguinous drainage is typical during this phase as new capillaries leak. The
inflammatory phase (B) is characterized by erythema, edema, and warmth in the
first 1–4 days. The maturation phase (D) involves scar remodeling and
strengthening over months to years.
2. The nurse is reviewing discharge instructions with a client who has a new
diagnosis of gastroesophageal reflux disease (GERD). Which statement by the
client indicates a need for further teaching?
A. "I will avoid lying down for at least 3 hours after eating."
B. "I should sleep with my head elevated on two pillows."
C. "I will eat small, frequent meals instead of three large meals."
D. "I can continue to drink a glass of red wine with dinner."
: Correct Answer : D
Rationale: Alcohol relaxes the lower esophageal sphincter (LES), increases gastric
acid secretion, and can directly irritate the esophageal mucosa, worsening GERD.
pg. 1
,2
Clients should be advised to avoid alcohol, caffeine, chocolate, peppermint, and
fatty/spicy foods. Sleeping with head elevated (B) reduces nocturnal reflux. Small,
frequent meals (C) decrease gastric distension and pressure.
3. The charge nurse is making assignments for the upcoming shift. Which client
should be assigned to the most experienced nurse?
A. A 24-year-old client with diabetic ketoacidosis on an insulin infusion whose last
blood glucose was 212 mg/dL
B. A 62-year-old client with a new diagnosis of lung cancer who is scheduled for a
biopsy in 2 hours
C. A 75-year-old client with a bowel resection 24 hours ago whose blood pressure
has dropped from 132/84 to 100/66 and heart rate increased from 78 to 104
D. A 40-year-old client with community-acquired pneumonia who is receiving IV
antibiotics and is ready for discharge planning
: Correct Answer : C
Rationale: The client in option C is exhibiting signs of hypovolemic shock or
internal hemorrhage (tachycardia and hypotension post-operatively). This client
requires frequent assessment and rapid intervention. The most experienced nurse
should manage a potentially unstable client. The DKA client (A) is improving. The
pre-op client (B) needs routine preparation. The pneumonia client (D) is stable
and nearing discharge.
4. The nurse is caring for a client with a central venous catheter. The insertion
site is red, tender, and the client has a temperature of 38.4°C (101.1°F). What is
the nurse's priority action?
A. Apply a warm compress to the insertion site
B. Notify the health care provider and prepare to change the catheter over a
guidewire
C. Draw blood cultures from the catheter and a peripheral site, then remove the
catheter
D. Administer the prescribed antipyretic and reassess in 30 minutes
pg. 2
,3
: Correct Answer : C
Rationale: The presentation suggests a central line-associated bloodstream
infection (CLABSI). The priority is to obtain cultures (both from the catheter hub
and a peripheral venipuncture) and then promptly remove the catheter when
infection is suspected. Administering an antipyretic (D) or applying a compress (A)
delays definitive treatment. Changing the catheter over a guidewire (B) is not
recommended when infection is suspected because it preserves the colonized
tract.
5. The nurse manager is evaluating a staff nurse's documentation. Which entry
best reflects appropriate documentation of an incident?
A. "Patient fell out of bed. Physician notified."
B. "Found patient on floor. Blood pressure stable. No injuries noted. Family
upset."
C. "Patient found lying on the floor beside the bed at 08:15. Denies pain. Full
range of motion in all extremities. Bedside rails were down. Provider notified at
08:20. Incident report filed."
D. "Error made in medication administration. Patient not harmed. Will monitor."
: Correct Answer : C
Rationale: Documentation of an incident should be factual, objective, and include
a description of the event, the patient's condition, interventions taken, and
notification of the provider. It should not include the word "error" (as that goes
on the incident report), assumptions, or opinions. The incident report itself is a
separate document and its existence is not mentioned in the medical record.
6. A client with terminal cancer tells the nurse, "I know I'm dying, but I just want
to see my daughter graduate next month." The nurse recognizes this statement
as an example of:
A. Denial
B. Anger
C. Bargaining
D. Acceptance
pg. 3
, 4
: Correct Answer : C
Rationale: Kübler-Ross's stages of grief include denial, anger, bargaining,
depression, and acceptance. The client is in the bargaining stage, making a deal
(to live until a specific event) in exchange for more time. The client acknowledges
the reality of death but is trying to postpone it. Denial (A) would involve refusing
to accept the diagnosis. Acceptance (D) is a state of peace.
7. The nurse is delegating tasks to the unlicensed assistive personnel (UAP).
Which task is appropriate for the UAP to perform?
A. Assess a client's breath sounds after a nebulizer treatment
B. Administer an enema to a client with a suspected bowel obstruction
C. Obtain vital signs on a client 1 hour after a blood transfusion was started
D. Ambulate a client who had a total hip replacement 12 hours ago
: Correct Answer : C
Rationale: Obtaining vital signs is within the UAP's scope for a stable client.
However, the nurse must interpret the data. Assessment (A) is a nursing function.
Administering an enema to a client with a suspected obstruction (B) is
contraindicated and requires nursing judgment. Ambulating a client post-hip
replacement (D) requires the nurse to assess the client's stability and need for
specific positioning/precautions, though in some facilities, UAPs ambulate stable
clients after initial nursing assessment. However, for the NCLEX, a task that
requires evaluation or assessment should not be delegated to a UAP. Option C
involves data collection (vital signs), which the UAP can perform and report to the
nurse.
8. A nurse is caring for a client who has a pulmonary artery catheter
(Swan-Ganz). The nurse notes a waveform that shifts from a clear pulmonary
artery tracing to a dampened, wedged tracing that remains even when the
balloon is deflated. The nurse should first:
A. Notify the provider immediately
B. Ask the client to cough forcefully
C. Attempt to aspirate blood from the distal port
D. Advance the catheter 1 cm
pg. 4
