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KAPLAN NCLEX-RN TRAINER #2 EXAM
QUESTIONS AND CORRECT ANSWERS
WITH DETAILED RATIONALES
CURRENT TESTING
1. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min
via nasal cannula. The nurse notes that the client’s respiratory rate has decreased from 24 to 10
breaths/min, and the client is difficult to arouse. Which action should the nurse take first?
A. Increase the oxygen flow rate to 4 L/min
B. Place the client in a high-Fowler’s position
C. Check the oxygen saturation level
D. Decrease or discontinue the oxygen and notify the provider Correct answer: D. Decrease
or discontinue the oxygen and notify the provider
Rationale: In COPD, high oxygen delivery can suppress the hypoxic drive, leading to
hypercapnia and respiratory depression. Decreasing or discontinuing oxygen is the
priority, followed by notifying the provider. Increasing oxygen would worsen the
condition.
2. A nurse is caring for a client with a new diagnosis of heart failure who is prescribed
furosemide (Lasix). Which finding requires immediate action?
A. Serum potassium level of 3.8 mEq/L
B. Weight loss of 1 kg in 24 hours
C. Blood pressure of 90/60 mm Hg with dizziness
D. Urinary output of 50 mL/hour
Correct answer: C. Blood pressure of 90/60 mm Hg with dizziness
Rationale: Furosemide can cause significant hypotension, especially with rapid diuresis. A
BP of 90/60 mm Hg with dizziness indicates hypovolemia and risk for falls or shock; the
nurse should hold the next dose and notify the provider. Potassium 3.8 is normal; weight
loss of 1 kg (2.2 lb) is expected; urine output 50 mL/hr is adequate.
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3. A client is admitted with diabetic ketoacidosis (DKA). Which laboratory finding is most
consistent with this diagnosis?
A. Serum bicarbonate of 22 mEq/L
B. Blood glucose of 180 mg/dL
C. Serum potassium of 2.9 mEq/L
D. Anion gap of 18 mEq/L
Correct answer: D. Anion gap of 18 mEq/L
Rationale: DKA is characterized by an elevated anion gap metabolic acidosis due to ketone
accumulation. Normal anion gap is 8–12; 18 is elevated. Bicarbonate is typically low (<18),
not normal; blood glucose is often >250 mg/dL; potassium may be normal, low, or high, but
initial hyperkalemia is common due to acidosis.
4. A nurse is providing discharge teaching to a client with a new prescription for warfarin.
Which statement by the client indicates a need for further teaching?
A. “I will use an electric razor instead of a blade.”
B. “I will avoid eating large amounts of green leafy vegetables.”
C. “I will get my blood tested regularly as ordered.”
D. “I will take ibuprofen for headaches.”
Correct answer: D. “I will take ibuprofen for headaches.” Rationale: Ibuprofen
and other NSAIDs increase the risk of gastrointestinal bleeding when taken with
warfarin. Acetaminophen is safer for pain/fever. Electric razors, consistent vitamin
K intake, and regular INR monitoring are appropriate.
5. A client is receiving a blood transfusion and reports chills, low back pain, and a feeling of
“impending doom.” The nurse’s priority action is to:
A. Slow the transfusion rate
B. Administer prescribed acetaminophen
C. Stop the transfusion and start normal saline
D. Obtain a blood culture from the client
Correct answer: C. Stop the transfusion and start normal saline Rationale: These
symptoms suggest an acute hemolytic transfusion reaction. The transfusion must be
stopped immediately, and IV saline should be infused to maintain access. The blood bag
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and tubing are sent to the blood bank for analysis. Notifying the provider follows after
stopping the transfusion.
6. A nurse is assessing a client with cirrhosis for signs of hepatic encephalopathy. Which
assessment finding is most indicative of this complication?
A. Asterixis (liver flap)
B. Jaundice
C. Palmar erythema
D. Spider angiomas
Correct answer: A. Asterixis (liver flap)
Rationale: Asterixis is a classic sign of hepatic encephalopathy due to ammonia
accumulation. Jaundice, palmar erythema, and spider angiomas are signs of chronic liver
disease but do not specifically indicate encephalopathy.
7. A postpartum client who is 2 hours after a vaginal delivery reports a heavy, gushing flow of
blood and a boggy uterus. The nurse’s priority action is to:
A. Increase the IV oxytocin infusion rate
B. Perform fundal massage
C. Place the client in Trendelenburg position
D. Notify the provider immediately
Correct answer: B. Perform fundal massage
Rationale: A boggy uterus indicates uterine atony, the most common cause of
postpartum hemorrhage. Fundal massage helps stimulate uterine contraction and is
the immediate first action. Increasing oxytocin and notifying the provider are
subsequent steps, but manual massage is priority.
8. A client with major depressive disorder is started on phenelzine (Nardil), a monoamine
oxidase inhibitor (MAOI). Which food should the nurse instruct the client to avoid?
A. Fresh apples
B. Baked chicken
C. Aged cheddar cheese
D. White rice
Correct answer: C. Aged cheddar cheese
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Rationale: MAOIs interact with tyramine-rich foods (aged cheese, cured meats, red
wine, beer) to cause hypertensive crisis. Fresh fruits, plain meats, and rice are safe.
The client must also avoid certain over-the-counter medications containing
decongestants.
9. A nurse is caring for a client with a chest tube after a thoracotomy. Which finding requires
immediate intervention?
A. Fluctuation (tidaling) of fluid in the water seal chamber
B. Gentle bubbling in the suction control chamber
C. Continuous bubbling in the water seal chamber
D. 100 mL of drainage in the collection chamber over 8 hours
Correct answer: C. Continuous bubbling in the water seal chamber
Rationale: Continuous bubbling in the water seal chamber indicates an air leak.
Fluctuation is normal; gentle bubbling in the suction chamber is expected with suction;
100 mL drainage over 8 hours is not excessive. An air leak must be located and managed
to prevent pneumothorax.
10. A client with a new tracheostomy has copious thick secretions. Which intervention is most
effective?
A. Instill 5 mL of normal saline into the tracheostomy before suctioning
B. Increase humidification and suction as needed
C. Change the inner cannula every 2 hours
D. Suction the tracheostomy every 15 minutes
Correct answer: B. Increase humidification and suction as needed
Rationale: Thick secretions are best managed with adequate humidification (heated
humidity or HME). Saline instillation is no longer routinely recommended as it may
dislodge biofilm and cause coughing. Suctioning should be based on client need, not a fixed
schedule. Inner cannula changes are done per protocol (usually daily or as needed).
11. A nurse is preparing to administer an intramuscular (IM) injection of a viscous
medication in the ventrogluteal site. Which needle length is most appropriate for an adult
of average size?
A. 1/2 inch
KAPLAN NCLEX-RN TRAINER #2 EXAM
QUESTIONS AND CORRECT ANSWERS
WITH DETAILED RATIONALES
CURRENT TESTING
1. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min
via nasal cannula. The nurse notes that the client’s respiratory rate has decreased from 24 to 10
breaths/min, and the client is difficult to arouse. Which action should the nurse take first?
A. Increase the oxygen flow rate to 4 L/min
B. Place the client in a high-Fowler’s position
C. Check the oxygen saturation level
D. Decrease or discontinue the oxygen and notify the provider Correct answer: D. Decrease
or discontinue the oxygen and notify the provider
Rationale: In COPD, high oxygen delivery can suppress the hypoxic drive, leading to
hypercapnia and respiratory depression. Decreasing or discontinuing oxygen is the
priority, followed by notifying the provider. Increasing oxygen would worsen the
condition.
2. A nurse is caring for a client with a new diagnosis of heart failure who is prescribed
furosemide (Lasix). Which finding requires immediate action?
A. Serum potassium level of 3.8 mEq/L
B. Weight loss of 1 kg in 24 hours
C. Blood pressure of 90/60 mm Hg with dizziness
D. Urinary output of 50 mL/hour
Correct answer: C. Blood pressure of 90/60 mm Hg with dizziness
Rationale: Furosemide can cause significant hypotension, especially with rapid diuresis. A
BP of 90/60 mm Hg with dizziness indicates hypovolemia and risk for falls or shock; the
nurse should hold the next dose and notify the provider. Potassium 3.8 is normal; weight
loss of 1 kg (2.2 lb) is expected; urine output 50 mL/hr is adequate.
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3. A client is admitted with diabetic ketoacidosis (DKA). Which laboratory finding is most
consistent with this diagnosis?
A. Serum bicarbonate of 22 mEq/L
B. Blood glucose of 180 mg/dL
C. Serum potassium of 2.9 mEq/L
D. Anion gap of 18 mEq/L
Correct answer: D. Anion gap of 18 mEq/L
Rationale: DKA is characterized by an elevated anion gap metabolic acidosis due to ketone
accumulation. Normal anion gap is 8–12; 18 is elevated. Bicarbonate is typically low (<18),
not normal; blood glucose is often >250 mg/dL; potassium may be normal, low, or high, but
initial hyperkalemia is common due to acidosis.
4. A nurse is providing discharge teaching to a client with a new prescription for warfarin.
Which statement by the client indicates a need for further teaching?
A. “I will use an electric razor instead of a blade.”
B. “I will avoid eating large amounts of green leafy vegetables.”
C. “I will get my blood tested regularly as ordered.”
D. “I will take ibuprofen for headaches.”
Correct answer: D. “I will take ibuprofen for headaches.” Rationale: Ibuprofen
and other NSAIDs increase the risk of gastrointestinal bleeding when taken with
warfarin. Acetaminophen is safer for pain/fever. Electric razors, consistent vitamin
K intake, and regular INR monitoring are appropriate.
5. A client is receiving a blood transfusion and reports chills, low back pain, and a feeling of
“impending doom.” The nurse’s priority action is to:
A. Slow the transfusion rate
B. Administer prescribed acetaminophen
C. Stop the transfusion and start normal saline
D. Obtain a blood culture from the client
Correct answer: C. Stop the transfusion and start normal saline Rationale: These
symptoms suggest an acute hemolytic transfusion reaction. The transfusion must be
stopped immediately, and IV saline should be infused to maintain access. The blood bag
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and tubing are sent to the blood bank for analysis. Notifying the provider follows after
stopping the transfusion.
6. A nurse is assessing a client with cirrhosis for signs of hepatic encephalopathy. Which
assessment finding is most indicative of this complication?
A. Asterixis (liver flap)
B. Jaundice
C. Palmar erythema
D. Spider angiomas
Correct answer: A. Asterixis (liver flap)
Rationale: Asterixis is a classic sign of hepatic encephalopathy due to ammonia
accumulation. Jaundice, palmar erythema, and spider angiomas are signs of chronic liver
disease but do not specifically indicate encephalopathy.
7. A postpartum client who is 2 hours after a vaginal delivery reports a heavy, gushing flow of
blood and a boggy uterus. The nurse’s priority action is to:
A. Increase the IV oxytocin infusion rate
B. Perform fundal massage
C. Place the client in Trendelenburg position
D. Notify the provider immediately
Correct answer: B. Perform fundal massage
Rationale: A boggy uterus indicates uterine atony, the most common cause of
postpartum hemorrhage. Fundal massage helps stimulate uterine contraction and is
the immediate first action. Increasing oxytocin and notifying the provider are
subsequent steps, but manual massage is priority.
8. A client with major depressive disorder is started on phenelzine (Nardil), a monoamine
oxidase inhibitor (MAOI). Which food should the nurse instruct the client to avoid?
A. Fresh apples
B. Baked chicken
C. Aged cheddar cheese
D. White rice
Correct answer: C. Aged cheddar cheese
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Rationale: MAOIs interact with tyramine-rich foods (aged cheese, cured meats, red
wine, beer) to cause hypertensive crisis. Fresh fruits, plain meats, and rice are safe.
The client must also avoid certain over-the-counter medications containing
decongestants.
9. A nurse is caring for a client with a chest tube after a thoracotomy. Which finding requires
immediate intervention?
A. Fluctuation (tidaling) of fluid in the water seal chamber
B. Gentle bubbling in the suction control chamber
C. Continuous bubbling in the water seal chamber
D. 100 mL of drainage in the collection chamber over 8 hours
Correct answer: C. Continuous bubbling in the water seal chamber
Rationale: Continuous bubbling in the water seal chamber indicates an air leak.
Fluctuation is normal; gentle bubbling in the suction chamber is expected with suction;
100 mL drainage over 8 hours is not excessive. An air leak must be located and managed
to prevent pneumothorax.
10. A client with a new tracheostomy has copious thick secretions. Which intervention is most
effective?
A. Instill 5 mL of normal saline into the tracheostomy before suctioning
B. Increase humidification and suction as needed
C. Change the inner cannula every 2 hours
D. Suction the tracheostomy every 15 minutes
Correct answer: B. Increase humidification and suction as needed
Rationale: Thick secretions are best managed with adequate humidification (heated
humidity or HME). Saline instillation is no longer routinely recommended as it may
dislodge biofilm and cause coughing. Suctioning should be based on client need, not a fixed
schedule. Inner cannula changes are done per protocol (usually daily or as needed).
11. A nurse is preparing to administer an intramuscular (IM) injection of a viscous
medication in the ventrogluteal site. Which needle length is most appropriate for an adult
of average size?
A. 1/2 inch
