NUR 3465 KAPLAN EXAM CAT 1 QUESTIONS AND ANSWERS.1. The nurse performs an assessment on a full-term newborn. Which finding does the nurse report to
the he... [Show More] alth care provider?
1. The client's blood pressure of 70/44 mm Hg.
2. The umbilical cord is whitish gray in color.
3. Bowel sounds cannot be auscultated in the abdomen.
4. The big toe dorsiflexes when the side of the foot is stroked.
Ans: 3
2. The nurse in an antepartum clinic has several phone messages from clients. Which client does the
nurse call first?
1. The client who is 10 weeks pregnant and reports vomiting after dinner for the past 5
days.
2. The client who is 18 weeks pregnant and reports a headache in the evening for the past
2 days.
3. The client who is 32 weeks pregnant and reports that her feet are swollen in the
morning.
4. The client who is 37 weeks pregnant and reports that her membranes have ruptured.
Ans: 4
3. The nurse prepares a medication in a prefilled syringe and notes that the syringe does not have a
label with the client's name. What action will the nurse take?
1. Notify the pharmacy.
2. Call the health care provider.
3. Label the syringe.
4. Administer the medication.
Ans: 1
4. The nurse plans to teach a local community group about chronic obstructive pulmonary disease
(COPD). Which information does the nurse include? (Select all that apply.)
1. Uncontrolled COPD can lead to cardiac disease.
2. Asthma in childhood leads to COPD later in life.
3. Cigarette smoking is the leading COPD risk factor.
4. More females are affected by COPD than males.
5. Co-existing illness may cause COPD exacerbation.
Ans: 1, 3,5
5. The nurse notes that a client requires protective isolation. Which additional client will the nurse
safely pair with the client in protective isolation?
1. Client with a urinary tract infection.
2. Client with a stage 3 sacral pressure ulcer.
3. Client with unstable diabetes mellitus.
4. Client recovering from surgery for a perforated bowel.
Ans: 3
6. A client who is pregnant asks the nurse what an elevated serum alpha-fetoprotein (AFP) level
indicates. Which information does the nurse provide to the mother?
1. Gestational diabetes.
2. A neural tube defects.
3. Trisomy 21 (Down syndrome).
4. Lack of lung maturity.
Ans: 1
7. The nurse notes that a toddler-age client has burn marks in various stages of healing and is fearful
of male health care professionals. Which action will the nurse take next?
1. Document the findings in the chart.
2. Talk to the nursing supervisor.
3. Ask the client what happened.
4. Discuss the findings with the health care provider.
Ans: 1
8. The nurse mentors a nursing student. The student asks which organization requires all clients to be
assessed for pain. Which response by the nurse is correct?
1. The National Council of State Boards of Nursing (NCSBN).
2. The American Nursing Association (ANA).
3. The Joint Commission.
4. The National League of Nursing (NLN).
Ans: 3
9. The nurse provides care for several clients. Which task does the nurse delegate to the nursing
assistive personnel (NAP)? (Select all that apply.)
1. Determine client’s pain level.
2. Perform walker use training.
3. Assist with meal trays.
4. Bathe a client with wounds.
5. Obtain routine vital signs.
Ans: 3, 4, 5
10. A client receives an antibiotic every 8 hours. The antibiotic has an onset of action of 2 hours and a
duration of action of 8 hours. The client is prescribed a peak blood level. If the medication is provided
at 1000, at which time will the nurse schedule the peak level to be drawn?
1. 1100.
2. 1200.
3. 1400.
4. 1800.
Ans: 3
11. The nurse provides care to a client at risk for hypercalcemia. Which action is most appropriate for
the nurse to take?
1. Encourage strict bed rest.
2. Limit dietary fiber.
3. Encourage oral fluids.
4. Hold prescribed zoledronate.
Ans: 3
12. The nurse provides care for several clients in Buck traction. Which client is at greatest risk for skin
breakdown?
1. An elderly client with severe Alzheimer disease.
2. An elderly client with a history of atrial fibrillation.
3. An elderly client with chronic bronchitis.
4. An elderly client with diverticulosis.
Ans: 1
13. The charge nurse reviews the medical records of several clients. Which documentation from a staff
nurse requires the charge nurse to follow-up?
1. “Returned from radiology department following a chest X-ray. Requesting lunch but
remains nothing by mouth until seen by the health care provider as prescribed.”
2. “Late – entry. Ambulated from bed to doorway without assistance. No shortness of
breath or diaphoresis noted. Vital signs remained within baseline after ambulating.”
3. “Intravenous catheter site in left antecubital space is red and warm to touch.
Intravenous solution infusing slowly. Catheter removed intact. New catheter placed in right forearm.”
4. “Found client sitting on floor. All four side rails were in upright position. Client reports no
pain. No abrasions or bleeding noted. Health care provider notified. Incident report completed.”
Ans: 4
14. The nurse delegates vital sign measurement to the nursing assistive personnel (NAP). Which
statement provides the best information for the nurse to give when delegating this task?
1. “Please obtain blood pressure, heart rate, respiratory rate, temperature, and pulse
oximetry. Let me know if anyone’s systolic blood pressure is <100 or >160, heart rate <60 or >100,
respiratory rate <12 or >20, temperature >100.50F (40.60C), or pulse oximetry <95%."
2. “Please obtain blood pressure, heart rate, respiratory rate, temperature, and pulse
oximetry. Report any readings outside the normal ranges."
3. “Please obtain blood pressure, heart rate, respiratory rate, temperature, pain rating, and
pulse oximetry. Let me know if anyone’s systolic blood pressure is <100 or >160, heart rate <60 or >100,
respiratory rate <12 or >20, temperature >100.50F (40.60C), pain level >5/10, or pulse oximetry <95%."
4. “Please obtain blood pressure, heart rate, respiratory rate, temperature, and pulse
oximetry. Let me know if anyone’s blood pressure is <100 or >160, heart rate <50, respiratory rate <12,
temperature >100.50F (45.60C), or pulse oximetry <93%."
Ans: 1 [Show Less]
