KAPLAN EXAM CAT 3 QUESTIONS AND ANSWERS

1. The nurse auscultates crackles throughout all lung fields and measures a heart rate of 132 bpm, a

respiratory rate of 30, and blood pressure of 102/54 mm Hg in a client recovering from an

esophagectomy. Which action will the nurse take first?

1. Place the client on continuous pulse oximetry.

2. Monitor the client for changes in blood pressure.

3. Notify the health care provider.

4. Assist the client to use the incentive spirometer.

2. The nurse assigns a client diagnosed with cancer who is receiving chemotherapy to a nursing

assistive personnel (NAP). Which instruction is most important for the nurse to include?

1. Perform hand hygiene frequently.

2. Wear a mask when entering the room.

3. Monitor the roommate forsigns of infection.

4. Monitor the amount of protein the client eats.

3. The nurse provides care for a client diagnosed with a bone infection. The client was given

intravenous morphine 3 hours ago and cannot have another dose for an hour. The client reports pain

that is rated as 6 out of 10. The nurse implements several nonpharmacological approaches. The

client’s pain level is now a 3 out of 10. Which action should the nurse take next?

1. Notify the health care provider.

2. Administerthe morphine early.

3. Instruct the client that the next dose cannot be given for an hour.

4. Ask the client what is an acceptable pain level.

4. The nurse provides care for a client who was in a car accident as the result of falling asleep at the

wheel. The client reports only being able to sleep 3 to 4 hours a night over the past month, due to

stress. The client reports waking up frequently during the night. Which outcome is most appropriate

for the nurse to include in the client’s plan of care?

week.

1. Client will verbalize a plan to implement a sleep promoting program within the next

2. Client will fall asleep with less difficulty over the next 2 weeks.

3. Client will achieve a more normal sleep pattern within 2 to 4 weeks.

4. Client will achieve an improved sense of adequate sleep over the next 4 weeks.

5. The nurse reviews medications prescribed for a client recovering from surgery. Which prescription

causes the nurse the most concern?

1. Diphenhydramine 50 mg PO at bedtime, as needed.

2. Furosemide 40 mg IV q.d.

3. Morphine sulfate 2 mg IV every hour, as needed, for pain.

4. Oxygen at 2 L/min via nasal cannula.

6. The nurse reads the result of a tuberculosis (TB) skin test on a client with no known risk factors for

TB. Which finding will the nurse interpret as a positive result?

1. Erythema of 5 or more millimeters.

2. Induration of 5 or more millimeters.

3. Induration of 10 or more millimeters.

4. Induration of 15 or more millimeters.

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7. The nurse provides care to an older adult clientsuspected of being a victim of physical abuse. Which

action is appropriate for the nurse to implement when providing care to the client? (Select all that

apply.)

1. Place the client in a single room near the nurses’ station.

3. Identify, collect, and preserve physical evidence of abuse.

4. Take photographsto documentsigns of physical abuse.

5. Use standardized tool to screen for elder mistreatment.

8. A client receiving an enema reports cramping and discomfort when the nurse releases the clamp

and places the container 12 inches above the client’s hip level. Which action will the nurse take next?

1. Instruct the client to take deep breaths.

2. Discontinue the enema.

3. Clamp the tubing.

4. Lower the enema bag below the level of the hips.

9. The nurse assesses clients waiting to be seen by the health care provider. Which client does the

nurse identify to be seen first?

1. Client with myasthenia gravisreporting double vision and drooping of the right eye lid.

2. Client with a flat 9 mm induration area at the site of a tuberculin skin test placed 48

hours ago.

3. Client with a mean arterial pressure of 80 mm Hg.

4. Client with lung disease reporting dyspnea after walking up stairs.

10. A client experiences wide QRS complexes on telemetry, numbness of the feet, and tingling of both

hands. Which medication will the nurse question before administering to this client?

1. Diltiazem.

2. Furosemide.

3. Spironolactone.

4. Metoprolol tartrate.

11. The nurse provides care for a client diagnosed with leukemia. The nurse notes the client has

vomited a large amount of bloody emesis. Which action should the nurse take first?

1. Measure the vomitus before dumping it.

2. Assessthe client’slast platelet count.

3. Notify the health care provider.

4. Complete a head to toe assessment.

12. The nurse isteaching a client who has undergone a cataract extraction with intraocular implant.

Which instruction does the nurse include in the discharge teaching? (Select all that apply.)

1. Avoid activitiesthat require bending over.

2. Place an eye shield on the surgical eye at bedtime.

3. Avoid lifting anything over 5 pounds.

4. Contact the surgeon if eye scratchiness occurs.

5. Take acetaminophen for minor eye discomfort.

13. An infant diagnosed with pertussis is being discharged home with the parents. Which information

will the nurse include in the parents’ teaching plan? (Select all that apply.)

2. Assess the client for bilateral injuries in ankles or wrist.

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1. Hand hygiene using an alcohol-based hand rub is effective against pertussis.

2. Family members and others in close contact with the infant should be vaccinated.

3. Airborne isolation precautions are required for 5 days after the start of antibiotic

therapy.

4. Pertussis is most severe forthe elderly.

5. Even if a person’s immunization statusfor pertussisis unknown, it is safe to immunize

again.

14. The nurse reviews the care needs for assigned clients. Which client will the nurse assess first?

1. Client with ulcerative colitis who reports rectal bleeding.

2. Client with an acute kidney injury with a urine output of 100 mL over the past 6 hours.

3. Client with angina pectoris who reports a headache after receiving a dose of prescribed

nitroglycerin.

4. Client with a radioactive implant for cervical cancer who is in the bathroom.

15. The nurse teaches a client how to self-administer nasal drops. Which statement is part of these

instructions?

1. “Occlude one nostril prior to instilling the drops.”

2. “Store the medication vial in the refrigerator between doses.”

3. “Shake the medication vial forseveral minutes before opening.”

4. “Sit with the neck flexed backward for 5 minutes after instilling the drops.”

16. The nurse assiststhe code team treating a client with asystole. Cardiopulmonary resuscitation

(CPR) is in process. Which direction by the code team leader requires the nurse to intervene?

1. “Push hard and push fast during compressions.”

2. “Give atropine 1 mg followed by an NS flush.”

3. “Give epinephrine 1 mg every 3 to 5 minutes.”

4. “Continue CPR for 2 minutes and then check rhythm.”

17. The nurse provides care to a 10-month-old infant. For which statement made by the parent will the

nurse intervene? (Select all that apply.)

1. “My child has a two-word vocabulary.”

2. “My child gained 1 ounce this week.”

3. “My child cannot walk unless I hold under the arms.”

4. “My child cries and spreadsthe arms in and out when I bump the crib.”

5. “My child’s soft spot on top of the head is still open.”

18. The charge nurse assigns several clients to a novice nurse who is fresh off unit orientation. Which

client will the charge nurse assign the novice nurse to provide care during this shift? (Select all that

apply.)

1. A client on airborne precautions for newly diagnosed tuberculosis(TB).

2. A client diagnosed with chronic obstructive pulmonary disease (COPD) discharging

tomorrow.

3. A client diagnosed with acute pneumonia on a bilevel positive airway pressure (BiPAP)

machine.

4. A client status postoperative for a vaginal hysterectomy done earlier in the day.

5. A toddler diagnosed with respiratory syncytial virus(RSV) admitted an hour ago.

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