NCLEX Fundamentals of Nursing Test Bank Exam
Verified Questions, Correct Answers, and Detailed
Explanations for Students||Already Graded A+
1. A nurse is caring for a client who is postoperative and has a prescription for
morphine every 4 hours. Which of the following actions should the nurse take
first?
A. Administer the morphine
B. Assess the client’s pain level
C. Encourage the client to use nonpharmacologic methods
D. Notify the provider of the prescription
Answer: B. Assess the client’s pain level
Rationale: The first action in the nursing process is always assessment.
Assessing pain determines the need for medication and guides care.
2. Which of the following demonstrates proper hand hygiene?
A. Rinsing hands with water only
B. Using alcohol-based sanitizer before and after patient contact
C. Wearing gloves instead of washing hands
D. Washing hands only if visibly soiled
Answer: B. Using alcohol-based sanitizer before and after patient contact
Rationale: Alcohol-based sanitizers are effective for routine hand hygiene and
prevent transmission of pathogens.
,3. A nurse is preparing to administer an intramuscular injection. Which site is
safest for an adult client?
A. Ventrogluteal
B. Deltoid
C. Dorsogluteal
D. Vastus lateralis
Answer: A. Ventrogluteal
Rationale: The ventrogluteal site is preferred because it avoids major nerves
and blood vessels and is suitable for larger volumes of medication.
4. A nurse is caring for a client with a nasogastric tube. Which action prevents
aspiration?
A. Placing the client supine during feeding
B. Elevating the head of the bed 30–45 degrees
C. Administering a rapid bolus of feeding
D. Checking tube placement once per day
Answer: B. Elevating the head of the bed 30–45 degrees
Rationale: Elevating the head reduces the risk of aspiration during enteral
feedings.
5. Which of the following is a sign of hypoglycemia in a client with diabetes?
A. Polyuria
,B. Shakiness and diaphoresis
C. Hot, flushed skin
D. Hypertension
Answer: B. Shakiness and diaphoresis
Rationale: Hypoglycemia causes autonomic symptoms such as tremors,
sweating, and anxiety due to low blood glucose.
6. A client with heart failure reports shortness of breath and edema. Which
action should the nurse take first?
A. Assess lung sounds and oxygen saturation
B. Administer prescribed diuretics
C. Encourage ambulation
D. Restrict fluids
Answer: A. Assess lung sounds and oxygen saturation
Rationale: Assessment is the first step; shortness of breath may indicate fluid
overload requiring immediate intervention.
7. When providing perineal care to a female client, the nurse should:
A. Wipe from back to front
B. Wipe from front to back
C. Use the same washcloth for both sides
D. Wash only the external area
, Answer: B. Wipe from front to back
Rationale: Wiping front to back prevents bacteria from the rectal area from
contaminating the urinary tract.
8. A nurse is caring for a client on contact precautions. Which PPE is required?
A. Mask and gloves
B. Gloves and gown
C. Gown and N95 respirator
D. Gloves, gown, and face shield
Answer: B. Gloves and gown
Rationale: Contact precautions require gloves and a gown to prevent spread of
microorganisms via direct or indirect contact.
9. A nurse is teaching a client about a low-sodium diet. Which food should the
client avoid?
A. Fresh fruits
B. Canned soups
C. Fresh vegetables
D. Brown rice
Answer: B. Canned soups
Rationale: Canned foods often contain high sodium levels and should be
limited in a low-sodium diet.
Verified Questions, Correct Answers, and Detailed
Explanations for Students||Already Graded A+
1. A nurse is caring for a client who is postoperative and has a prescription for
morphine every 4 hours. Which of the following actions should the nurse take
first?
A. Administer the morphine
B. Assess the client’s pain level
C. Encourage the client to use nonpharmacologic methods
D. Notify the provider of the prescription
Answer: B. Assess the client’s pain level
Rationale: The first action in the nursing process is always assessment.
Assessing pain determines the need for medication and guides care.
2. Which of the following demonstrates proper hand hygiene?
A. Rinsing hands with water only
B. Using alcohol-based sanitizer before and after patient contact
C. Wearing gloves instead of washing hands
D. Washing hands only if visibly soiled
Answer: B. Using alcohol-based sanitizer before and after patient contact
Rationale: Alcohol-based sanitizers are effective for routine hand hygiene and
prevent transmission of pathogens.
,3. A nurse is preparing to administer an intramuscular injection. Which site is
safest for an adult client?
A. Ventrogluteal
B. Deltoid
C. Dorsogluteal
D. Vastus lateralis
Answer: A. Ventrogluteal
Rationale: The ventrogluteal site is preferred because it avoids major nerves
and blood vessels and is suitable for larger volumes of medication.
4. A nurse is caring for a client with a nasogastric tube. Which action prevents
aspiration?
A. Placing the client supine during feeding
B. Elevating the head of the bed 30–45 degrees
C. Administering a rapid bolus of feeding
D. Checking tube placement once per day
Answer: B. Elevating the head of the bed 30–45 degrees
Rationale: Elevating the head reduces the risk of aspiration during enteral
feedings.
5. Which of the following is a sign of hypoglycemia in a client with diabetes?
A. Polyuria
,B. Shakiness and diaphoresis
C. Hot, flushed skin
D. Hypertension
Answer: B. Shakiness and diaphoresis
Rationale: Hypoglycemia causes autonomic symptoms such as tremors,
sweating, and anxiety due to low blood glucose.
6. A client with heart failure reports shortness of breath and edema. Which
action should the nurse take first?
A. Assess lung sounds and oxygen saturation
B. Administer prescribed diuretics
C. Encourage ambulation
D. Restrict fluids
Answer: A. Assess lung sounds and oxygen saturation
Rationale: Assessment is the first step; shortness of breath may indicate fluid
overload requiring immediate intervention.
7. When providing perineal care to a female client, the nurse should:
A. Wipe from back to front
B. Wipe from front to back
C. Use the same washcloth for both sides
D. Wash only the external area
, Answer: B. Wipe from front to back
Rationale: Wiping front to back prevents bacteria from the rectal area from
contaminating the urinary tract.
8. A nurse is caring for a client on contact precautions. Which PPE is required?
A. Mask and gloves
B. Gloves and gown
C. Gown and N95 respirator
D. Gloves, gown, and face shield
Answer: B. Gloves and gown
Rationale: Contact precautions require gloves and a gown to prevent spread of
microorganisms via direct or indirect contact.
9. A nurse is teaching a client about a low-sodium diet. Which food should the
client avoid?
A. Fresh fruits
B. Canned soups
C. Fresh vegetables
D. Brown rice
Answer: B. Canned soups
Rationale: Canned foods often contain high sodium levels and should be
limited in a low-sodium diet.
