TEST BANK – FUNDAMENTAL CMS
PROCTORED EXAM 2025/2026 | 400 VERIFIED
NURSING FUNDAMENTALS QUESTIONS WITH
CORRECT ANSWERS & DETAILED RATIONALES
| NCLEX, ATI, HESI STUDY GUIDE FOR WGU,
UNITEK, RASMUSSEN, CHAMBERLAIN &
EXCELSIOR
TEST BANK – FUNDAMENTAL CMS PROCTORED EXAM
400 VERIFIED NURSING FUNDAMENTALS QUESTIONS | NCLEX · ATI · HESI
WGU · UNITEK · RASMUSSEN · CHAMBERLAIN · EXCELSIOR
1. A nurse is preparing to perform hand hygiene. Which situation requires the use
of soap and water rather than an alcohol-based hand rub?
A. Before donning sterile gloves for a procedure B. After touching a patient's intact skin
C. After caring for a patient with Clostridioides difficile infection D. Before administering
oral medications E. After removing non-sterile gloves
CORRECT ANSWER: C. After caring for a patient with Clostridioides
difficile infection RATIONALE: Alcohol-based hand rubs are ineffective against
C. difficile spores. Soap and water mechanically remove spores from the hands and are
required after caring for patients with C. difficile, norovirus, or anthrax exposure.
2. A nurse is assessing a patient's blood pressure and obtains a reading of 158/96
mmHg. How should the nurse classify this finding according to current
guidelines?
A. Normal blood pressure B. Elevated blood pressure C. Stage 1 hypertension D. Stage
2 hypertension E. Hypertensive crisis
CORRECT ANSWER: D. Stage 2 hypertension RATIONALE:
According to the American College of Cardiology/AHA guidelines, Stage 2 hypertension
is defined as systolic ≥140 mmHg or diastolic ≥90 mmHg. A reading of 158/96 mmHg
meets both criteria for Stage 2 hypertension.
,3. The nurse is caring for a postoperative patient who is at risk for deep vein
thrombosis (DVT). Which intervention is the priority?
A. Administer anticoagulants as ordered B. Apply sequential compression devices
(SCDs) to the lower extremities C. Encourage increased fluid intake D. Elevate the head
of bed to 30 degrees E. Perform passive range-of-motion exercises every shift
CORRECT ANSWER: B. Apply sequential compression devices (SCDs) to
the lower extremities RATIONALE: SCDs are a mechanical prophylaxis that
should be applied immediately postoperatively to prevent venous stasis, which is a
primary cause of DVT. They are the priority intervention until anticoagulants are ordered
and deemed safe by the provider.
4. A nurse is preparing to administer a medication via nasogastric (NG) tube.
What is the nurse's priority action before administering the medication?
A. Flush the tube with 30 mL of water B. Verify tube placement C. Check the patient's
allergies D. Crush all tablets and dissolve in water E. Position the patient in supine
position
CORRECT ANSWER: B. Verify tube placement RATIONALE: Before
administering anything through an NG tube, verifying tube placement is the priority to
prevent aspiration. Placement is confirmed by checking pH of aspirate (≤5.5) or
radiographic confirmation. Flushing and positioning follow placement verification.
5. A patient tells the nurse, "I don't want any more blood transfusions because of
my religious beliefs." The patient is alert and oriented. What is the most
appropriate nursing action?
A. Contact the patient's family to discuss the decision B. Notify the physician and
document the patient's refusal C. Explain the risks of refusing treatment and encourage
reconsideration D. Administer the transfusion because it is medically necessary E. Ask
the charge nurse to speak with the patient
CORRECT ANSWER: B. Notify the physician and document the patient's
refusal RATIONALE: A competent, alert, and oriented adult has the legal and
ethical right to refuse any treatment, including blood transfusions, regardless of religious
,or personal reasons. The nurse must respect patient autonomy, notify the provider, and
document the refusal thoroughly.
6. The nurse is assessing a patient's wound and notes the drainage is thick,
yellow-green, and has a foul odor. How should the nurse document this type of
drainage?
A. Sanguineous B. Serosanguineous C. Serous D. Purulent E. Fibrinous
CORRECT ANSWER: D. Purulent RATIONALE: Purulent drainage is
thick, opaque, and yellow, green, or brown in color with a foul odor. It indicates infection
and the presence of white blood cells, bacteria, and cellular debris. Sanguineous is
bloody; serosanguineous is pink-tinged; serous is clear/watery.
7. A nurse is caring for a patient on contact precautions. Which personal
protective equipment (PPE) must the nurse wear upon entering the patient's
room?
A. Mask and gloves only B. Gown and gloves C. Gown, gloves, and N95 respirator D.
Gloves only E. Gown, gloves, mask, and eye protection
CORRECT ANSWER: B. Gown and gloves RATIONALE: Contact
precautions require a gown and gloves upon entry into the patient's room to prevent
transmission of organisms spread through direct or indirect contact. An N95 respirator is
required for airborne precautions; a surgical mask is for droplet precautions.
8. The nurse is teaching a patient about the use of a metered-dose inhaler (MDI).
Which statement by the patient indicates the need for further teaching?
A. "I will shake the inhaler before each use." B. "I will breathe in slowly and deeply when
I press the inhaler." C. "I will hold my breath for about 10 seconds after inhaling." D. "I
will take two puffs back to back without waiting." E. "I will rinse my mouth after using my
corticosteroid inhaler."
CORRECT ANSWER: D. "I will take two puffs back to back without
waiting." RATIONALE: When two puffs are prescribed, the patient should wait
1 minute between puffs to allow the first dose to open airways so the second dose can
penetrate deeper. Taking both puffs consecutively without waiting reduces effectiveness
and increases side effects.
, 9. A nurse is preparing to insert a urinary catheter for a female patient. What is the
correct sequence for cleansing the perineum?
A. From the vagina toward the rectum, using a circular motion B. From the rectum
toward the urethra C. The labia majora first, then the labia minora, then the urethral
meatus D. The urethral meatus first, then the labia minora, then the labia majora E. In
any direction as long as sterile technique is maintained
CORRECT ANSWER: C. The labia majora first, then the labia minora, then
the urethral meatus RATIONALE: Cleansing proceeds from the outermost to
innermost structures (labia majora → labia minora → urethral meatus) using a front-to-
back motion to prevent contamination of the urethral meatus with rectal flora, which
reduces the risk of catheter-associated urinary tract infections (CAUTIs).
10. The nurse is caring for a patient who requires restraints. Which action best
reflects the nurse's understanding of restraint use?
A. Apply restraints whenever a patient is confused B. Document restraint use at the end
of the shift C. Assess the restrained patient every 2 hours D. Obtain a physician's order
and assess the patient every 15–30 minutes E. Leave restraints in place continuously
once applied to maintain safety
CORRECT ANSWER: D. Obtain a physician's order and assess the patient
every 15–30 minutes RATIONALE: Restraints require a physician's order and
must be the least restrictive option used only when alternatives have failed. The nurse
must assess a restrained patient every 15–30 minutes, offer release, ROM exercises,
toileting, and hydration at least every 2 hours, and document regularly.
11. A nurse is preparing to administer an intramuscular (IM) injection to an adult
patient. Which site is preferred for IM injections due to its distance from major
nerves and blood vessels?
A. Dorsogluteal B. Deltoid C. Rectus femoris D. Ventrogluteal E. Vastus lateralis
CORRECT ANSWER: D. Ventrogluteal RATIONALE: The ventrogluteal
site is the preferred IM injection site for adults because it has no major nerves or blood
vessels nearby, has a large muscle mass, and is not near the sciatic nerve (unlike the
dorsogluteal site). The vastus lateralis is preferred for infants and children.
PROCTORED EXAM 2025/2026 | 400 VERIFIED
NURSING FUNDAMENTALS QUESTIONS WITH
CORRECT ANSWERS & DETAILED RATIONALES
| NCLEX, ATI, HESI STUDY GUIDE FOR WGU,
UNITEK, RASMUSSEN, CHAMBERLAIN &
EXCELSIOR
TEST BANK – FUNDAMENTAL CMS PROCTORED EXAM
400 VERIFIED NURSING FUNDAMENTALS QUESTIONS | NCLEX · ATI · HESI
WGU · UNITEK · RASMUSSEN · CHAMBERLAIN · EXCELSIOR
1. A nurse is preparing to perform hand hygiene. Which situation requires the use
of soap and water rather than an alcohol-based hand rub?
A. Before donning sterile gloves for a procedure B. After touching a patient's intact skin
C. After caring for a patient with Clostridioides difficile infection D. Before administering
oral medications E. After removing non-sterile gloves
CORRECT ANSWER: C. After caring for a patient with Clostridioides
difficile infection RATIONALE: Alcohol-based hand rubs are ineffective against
C. difficile spores. Soap and water mechanically remove spores from the hands and are
required after caring for patients with C. difficile, norovirus, or anthrax exposure.
2. A nurse is assessing a patient's blood pressure and obtains a reading of 158/96
mmHg. How should the nurse classify this finding according to current
guidelines?
A. Normal blood pressure B. Elevated blood pressure C. Stage 1 hypertension D. Stage
2 hypertension E. Hypertensive crisis
CORRECT ANSWER: D. Stage 2 hypertension RATIONALE:
According to the American College of Cardiology/AHA guidelines, Stage 2 hypertension
is defined as systolic ≥140 mmHg or diastolic ≥90 mmHg. A reading of 158/96 mmHg
meets both criteria for Stage 2 hypertension.
,3. The nurse is caring for a postoperative patient who is at risk for deep vein
thrombosis (DVT). Which intervention is the priority?
A. Administer anticoagulants as ordered B. Apply sequential compression devices
(SCDs) to the lower extremities C. Encourage increased fluid intake D. Elevate the head
of bed to 30 degrees E. Perform passive range-of-motion exercises every shift
CORRECT ANSWER: B. Apply sequential compression devices (SCDs) to
the lower extremities RATIONALE: SCDs are a mechanical prophylaxis that
should be applied immediately postoperatively to prevent venous stasis, which is a
primary cause of DVT. They are the priority intervention until anticoagulants are ordered
and deemed safe by the provider.
4. A nurse is preparing to administer a medication via nasogastric (NG) tube.
What is the nurse's priority action before administering the medication?
A. Flush the tube with 30 mL of water B. Verify tube placement C. Check the patient's
allergies D. Crush all tablets and dissolve in water E. Position the patient in supine
position
CORRECT ANSWER: B. Verify tube placement RATIONALE: Before
administering anything through an NG tube, verifying tube placement is the priority to
prevent aspiration. Placement is confirmed by checking pH of aspirate (≤5.5) or
radiographic confirmation. Flushing and positioning follow placement verification.
5. A patient tells the nurse, "I don't want any more blood transfusions because of
my religious beliefs." The patient is alert and oriented. What is the most
appropriate nursing action?
A. Contact the patient's family to discuss the decision B. Notify the physician and
document the patient's refusal C. Explain the risks of refusing treatment and encourage
reconsideration D. Administer the transfusion because it is medically necessary E. Ask
the charge nurse to speak with the patient
CORRECT ANSWER: B. Notify the physician and document the patient's
refusal RATIONALE: A competent, alert, and oriented adult has the legal and
ethical right to refuse any treatment, including blood transfusions, regardless of religious
,or personal reasons. The nurse must respect patient autonomy, notify the provider, and
document the refusal thoroughly.
6. The nurse is assessing a patient's wound and notes the drainage is thick,
yellow-green, and has a foul odor. How should the nurse document this type of
drainage?
A. Sanguineous B. Serosanguineous C. Serous D. Purulent E. Fibrinous
CORRECT ANSWER: D. Purulent RATIONALE: Purulent drainage is
thick, opaque, and yellow, green, or brown in color with a foul odor. It indicates infection
and the presence of white blood cells, bacteria, and cellular debris. Sanguineous is
bloody; serosanguineous is pink-tinged; serous is clear/watery.
7. A nurse is caring for a patient on contact precautions. Which personal
protective equipment (PPE) must the nurse wear upon entering the patient's
room?
A. Mask and gloves only B. Gown and gloves C. Gown, gloves, and N95 respirator D.
Gloves only E. Gown, gloves, mask, and eye protection
CORRECT ANSWER: B. Gown and gloves RATIONALE: Contact
precautions require a gown and gloves upon entry into the patient's room to prevent
transmission of organisms spread through direct or indirect contact. An N95 respirator is
required for airborne precautions; a surgical mask is for droplet precautions.
8. The nurse is teaching a patient about the use of a metered-dose inhaler (MDI).
Which statement by the patient indicates the need for further teaching?
A. "I will shake the inhaler before each use." B. "I will breathe in slowly and deeply when
I press the inhaler." C. "I will hold my breath for about 10 seconds after inhaling." D. "I
will take two puffs back to back without waiting." E. "I will rinse my mouth after using my
corticosteroid inhaler."
CORRECT ANSWER: D. "I will take two puffs back to back without
waiting." RATIONALE: When two puffs are prescribed, the patient should wait
1 minute between puffs to allow the first dose to open airways so the second dose can
penetrate deeper. Taking both puffs consecutively without waiting reduces effectiveness
and increases side effects.
, 9. A nurse is preparing to insert a urinary catheter for a female patient. What is the
correct sequence for cleansing the perineum?
A. From the vagina toward the rectum, using a circular motion B. From the rectum
toward the urethra C. The labia majora first, then the labia minora, then the urethral
meatus D. The urethral meatus first, then the labia minora, then the labia majora E. In
any direction as long as sterile technique is maintained
CORRECT ANSWER: C. The labia majora first, then the labia minora, then
the urethral meatus RATIONALE: Cleansing proceeds from the outermost to
innermost structures (labia majora → labia minora → urethral meatus) using a front-to-
back motion to prevent contamination of the urethral meatus with rectal flora, which
reduces the risk of catheter-associated urinary tract infections (CAUTIs).
10. The nurse is caring for a patient who requires restraints. Which action best
reflects the nurse's understanding of restraint use?
A. Apply restraints whenever a patient is confused B. Document restraint use at the end
of the shift C. Assess the restrained patient every 2 hours D. Obtain a physician's order
and assess the patient every 15–30 minutes E. Leave restraints in place continuously
once applied to maintain safety
CORRECT ANSWER: D. Obtain a physician's order and assess the patient
every 15–30 minutes RATIONALE: Restraints require a physician's order and
must be the least restrictive option used only when alternatives have failed. The nurse
must assess a restrained patient every 15–30 minutes, offer release, ROM exercises,
toileting, and hydration at least every 2 hours, and document regularly.
11. A nurse is preparing to administer an intramuscular (IM) injection to an adult
patient. Which site is preferred for IM injections due to its distance from major
nerves and blood vessels?
A. Dorsogluteal B. Deltoid C. Rectus femoris D. Ventrogluteal E. Vastus lateralis
CORRECT ANSWER: D. Ventrogluteal RATIONALE: The ventrogluteal
site is the preferred IM injection site for adults because it has no major nerves or blood
vessels nearby, has a large muscle mass, and is not near the sciatic nerve (unlike the
dorsogluteal site). The vastus lateralis is preferred for infants and children.
