Davis Advantage for Fundamentals of Nursing Complete
Study Guide, Comprehensive RN Nursing Fundamentals
Review, Exam Prep Questions and Answers with Rationales,
Clinical Skills Mastery, and High-Yield NCLEX Foundation
Success Resource for Nursing Students
Question 1: Which action by the nurse best demonstrates the principle of aseptic technique
when preparing a sterile field?
A. Placing sterile items within 1 inch of the edge of the sterile drape
B. Reaching over the sterile field to retrieve an item from the opposite side
C. Keeping sterile gloved hands above waist level and within sight at all times
D. Using non-sterile forceps to transfer sterile supplies onto the field
CORRECT ANSWER: C. Keeping sterile gloved hands above waist level and within sight at all
times
Rationale: Maintaining sterile gloved hands above waist level and within the nurse's line of
sight prevents contamination from unseen sources or contact with non-sterile surfaces. Items
within 1 inch of the sterile drape edge are considered contaminated, reaching over the field
introduces contamination risk, and non-sterile forceps cannot be used to handle sterile items
without compromising sterility.
Question 2: A nurse is assessing a client's pain using the PQRST mnemonic. Which question
corresponds to the "R" component?
A. "What makes the pain better or worse?"
B. "Can you describe the quality of the pain?"
C. "Where is the pain located and does it radiate?"
D. "On a scale of 0 to 10, how intense is the pain?"
CORRECT ANSWER: C. "Where is the pain located and does it radiate?"
Rationale: In the PQRST pain assessment mnemonic, "R" stands for Region/Radiation, which
evaluates the location of pain and whether it spreads to other areas. Option A addresses
provocation/palliation, B addresses quality, and D addresses severity.
Question 3: When administering medications via the intramuscular route, which site is
preferred for an adult client receiving a vaccine?
A. Ventrogluteal
B. Deltoid
C. Vastus lateralis
D. Dorsogluteal
CORRECT ANSWER: B. Deltoid
Rationale: The deltoid muscle is the preferred site for adult intramuscular vaccine
administration due to its accessibility, adequate muscle mass for small-volume injections (up to
2 mL), and distance from major nerves and vessels. The ventrogluteal site is preferred for larger
volumes or viscous medications, while the dorsogluteal site is avoided due to proximity to the
sciatic nerve.
Question 4: Which finding indicates that a client is experiencing effective oxygenation?
A. Oxygen saturation of 92% on room air
B. Capillary refill time of 4 seconds
,C. Respiratory rate of 16 breaths per minute with unlabored effort
D. Use of accessory muscles during inspiration
CORRECT ANSWER: C. Respiratory rate of 16 breaths per minute with unlabored effort
Rationale: A respiratory rate of 12-20 breaths per minute with unlabored effort indicates
adequate ventilation and oxygenation in adults. An oxygen saturation of 92% is below the
expected range (95-100%), capillary refill >3 seconds suggests poor perfusion, and accessory
muscle use indicates respiratory distress.
Question 5: A nurse is preparing to insert an indwelling urinary catheter in a female client.
Which action demonstrates proper technique to reduce infection risk?
A. Cleaning the meatus with a single stroke from back to front
B. Using sterile gloves and maintaining sterile technique throughout the procedure
C. Inflating the balloon with 10 mL of sterile water before insertion
D. Securing the catheter tubing to the client's inner thigh with adhesive tape
CORRECT ANSWER: B. Using sterile gloves and maintaining sterile technique throughout the
procedure
Rationale: Maintaining sterile technique during urinary catheter insertion is critical to prevent
catheter-associated urinary tract infections (CAUTIs). Cleaning should be front-to-back with
multiple sterile swabs, the balloon is inflated after insertion and urine return is confirmed, and
securement should use a commercial device to prevent urethral traction.
Question 6: Which assessment finding requires immediate intervention for a client receiving
intravenous potassium chloride?
A. Urine output of 40 mL/hr
B. Serum potassium level of 4.2 mEq/L
C. Burning sensation at the IV site
D. Heart rate of 88 beats per minute
CORRECT ANSWER: C. Burning sensation at the IV site
Rationale: Potassium chloride is highly irritating to veins and can cause phlebitis or tissue
necrosis if extravasation occurs. A burning sensation at the IV site requires immediate
assessment and possible discontinuation of the infusion. The other findings are within normal
limits and do not indicate an urgent complication.
Question 7: When performing hand hygiene, which situation requires the use of soap and
water rather than an alcohol-based hand rub?
A. After removing gloves following routine vital sign assessment
B. Before preparing and administering medications
C. After caring for a client with Clostridioides difficile infection
D. After touching the client's intact skin during bathing
CORRECT ANSWER: C. After caring for a client with Clostridioides difficile infection
Rationale: Alcohol-based hand rubs are ineffective against C. difficile spores; soap and water
mechanical friction is required to physically remove spores from hands. For all other situations
listed, alcohol-based hand rubs are appropriate and preferred when hands are not visibly
soiled.
, Question 8: A nurse is teaching a client about proper use of a metered-dose inhaler (MDI)
with a spacer. Which statement by the client indicates correct understanding?
A. "I should shake the inhaler vigorously after placing it in the spacer."
B. "I will breathe in slowly and deeply after actuating the inhaler."
C. "I need to exhale forcefully into the spacer before inhaling the medication."
D. "I should rinse my mouth with water after using a corticosteroid inhaler."
CORRECT ANSWER: D. "I should rinse my mouth with water after using a corticosteroid
inhaler."
Rationale: Rinsing the mouth after corticosteroid inhaler use reduces the risk of oral candidiasis
and dysphonia. The inhaler should be shaken before placing in the spacer, the client actuates
the inhaler then inhales slowly and deeply, and exhalation should occur before placing the
spacer in the mouth, not into it.
Question 9: Which action by the nurse best supports therapeutic communication when a
client expresses anxiety about an upcoming surgery?
A. Stating, "There's no need to worry; the surgeon is very experienced."
B. Asking, "What specifically about the surgery concerns you the most?"
C. Changing the subject to discuss postoperative pain management options.
D. Reassuring the client that many people undergo this procedure safely.
CORRECT ANSWER: B. Asking, "What specifically about the surgery concerns you the most?"
Rationale: Open-ended questions encourage clients to express feelings and concerns,
facilitating therapeutic communication and allowing the nurse to address specific fears. False
reassurance, changing the subject, or minimizing concerns blocks communication and fails to
address the client's emotional needs.
Question 10: A nurse is calculating the drip rate for an IV infusion of 1000 mL normal saline to
be administered over 8 hours using tubing with a drop factor of 15 gtt/mL. What is the
correct drip rate in drops per minute?
A. 21 gtt/min
B. 31 gtt/min
C. 42 gtt/min
D. 63 gtt/min
CORRECT ANSWER: B. 31 gtt/min
Rationale: The formula is (Volume in mL × Drop factor) ÷ Time in minutes. Calculation: (1000 mL
× 15 gtt/mL) ÷ (8 hours × 60 min) = 15,000 ÷ 480 = 31.25, rounded to 31 gtt/min. Accurate drip
rate calculation ensures safe and timely fluid administration.
Question 11: Which finding is the earliest indicator of hypoxia in an adult client?
A. Cyanosis of the lips and nail beds
B. Restlessness and confusion
C. Bradycardia and hypotension
D. Use of accessory muscles for breathing
CORRECT ANSWER: B. Restlessness and confusion
Rationale: Restlessness, anxiety, and confusion are early neurological signs of hypoxia due to
the brain's high oxygen demand. Cyanosis is a late sign, bradycardia and hypotension occur in
Study Guide, Comprehensive RN Nursing Fundamentals
Review, Exam Prep Questions and Answers with Rationales,
Clinical Skills Mastery, and High-Yield NCLEX Foundation
Success Resource for Nursing Students
Question 1: Which action by the nurse best demonstrates the principle of aseptic technique
when preparing a sterile field?
A. Placing sterile items within 1 inch of the edge of the sterile drape
B. Reaching over the sterile field to retrieve an item from the opposite side
C. Keeping sterile gloved hands above waist level and within sight at all times
D. Using non-sterile forceps to transfer sterile supplies onto the field
CORRECT ANSWER: C. Keeping sterile gloved hands above waist level and within sight at all
times
Rationale: Maintaining sterile gloved hands above waist level and within the nurse's line of
sight prevents contamination from unseen sources or contact with non-sterile surfaces. Items
within 1 inch of the sterile drape edge are considered contaminated, reaching over the field
introduces contamination risk, and non-sterile forceps cannot be used to handle sterile items
without compromising sterility.
Question 2: A nurse is assessing a client's pain using the PQRST mnemonic. Which question
corresponds to the "R" component?
A. "What makes the pain better or worse?"
B. "Can you describe the quality of the pain?"
C. "Where is the pain located and does it radiate?"
D. "On a scale of 0 to 10, how intense is the pain?"
CORRECT ANSWER: C. "Where is the pain located and does it radiate?"
Rationale: In the PQRST pain assessment mnemonic, "R" stands for Region/Radiation, which
evaluates the location of pain and whether it spreads to other areas. Option A addresses
provocation/palliation, B addresses quality, and D addresses severity.
Question 3: When administering medications via the intramuscular route, which site is
preferred for an adult client receiving a vaccine?
A. Ventrogluteal
B. Deltoid
C. Vastus lateralis
D. Dorsogluteal
CORRECT ANSWER: B. Deltoid
Rationale: The deltoid muscle is the preferred site for adult intramuscular vaccine
administration due to its accessibility, adequate muscle mass for small-volume injections (up to
2 mL), and distance from major nerves and vessels. The ventrogluteal site is preferred for larger
volumes or viscous medications, while the dorsogluteal site is avoided due to proximity to the
sciatic nerve.
Question 4: Which finding indicates that a client is experiencing effective oxygenation?
A. Oxygen saturation of 92% on room air
B. Capillary refill time of 4 seconds
,C. Respiratory rate of 16 breaths per minute with unlabored effort
D. Use of accessory muscles during inspiration
CORRECT ANSWER: C. Respiratory rate of 16 breaths per minute with unlabored effort
Rationale: A respiratory rate of 12-20 breaths per minute with unlabored effort indicates
adequate ventilation and oxygenation in adults. An oxygen saturation of 92% is below the
expected range (95-100%), capillary refill >3 seconds suggests poor perfusion, and accessory
muscle use indicates respiratory distress.
Question 5: A nurse is preparing to insert an indwelling urinary catheter in a female client.
Which action demonstrates proper technique to reduce infection risk?
A. Cleaning the meatus with a single stroke from back to front
B. Using sterile gloves and maintaining sterile technique throughout the procedure
C. Inflating the balloon with 10 mL of sterile water before insertion
D. Securing the catheter tubing to the client's inner thigh with adhesive tape
CORRECT ANSWER: B. Using sterile gloves and maintaining sterile technique throughout the
procedure
Rationale: Maintaining sterile technique during urinary catheter insertion is critical to prevent
catheter-associated urinary tract infections (CAUTIs). Cleaning should be front-to-back with
multiple sterile swabs, the balloon is inflated after insertion and urine return is confirmed, and
securement should use a commercial device to prevent urethral traction.
Question 6: Which assessment finding requires immediate intervention for a client receiving
intravenous potassium chloride?
A. Urine output of 40 mL/hr
B. Serum potassium level of 4.2 mEq/L
C. Burning sensation at the IV site
D. Heart rate of 88 beats per minute
CORRECT ANSWER: C. Burning sensation at the IV site
Rationale: Potassium chloride is highly irritating to veins and can cause phlebitis or tissue
necrosis if extravasation occurs. A burning sensation at the IV site requires immediate
assessment and possible discontinuation of the infusion. The other findings are within normal
limits and do not indicate an urgent complication.
Question 7: When performing hand hygiene, which situation requires the use of soap and
water rather than an alcohol-based hand rub?
A. After removing gloves following routine vital sign assessment
B. Before preparing and administering medications
C. After caring for a client with Clostridioides difficile infection
D. After touching the client's intact skin during bathing
CORRECT ANSWER: C. After caring for a client with Clostridioides difficile infection
Rationale: Alcohol-based hand rubs are ineffective against C. difficile spores; soap and water
mechanical friction is required to physically remove spores from hands. For all other situations
listed, alcohol-based hand rubs are appropriate and preferred when hands are not visibly
soiled.
, Question 8: A nurse is teaching a client about proper use of a metered-dose inhaler (MDI)
with a spacer. Which statement by the client indicates correct understanding?
A. "I should shake the inhaler vigorously after placing it in the spacer."
B. "I will breathe in slowly and deeply after actuating the inhaler."
C. "I need to exhale forcefully into the spacer before inhaling the medication."
D. "I should rinse my mouth with water after using a corticosteroid inhaler."
CORRECT ANSWER: D. "I should rinse my mouth with water after using a corticosteroid
inhaler."
Rationale: Rinsing the mouth after corticosteroid inhaler use reduces the risk of oral candidiasis
and dysphonia. The inhaler should be shaken before placing in the spacer, the client actuates
the inhaler then inhales slowly and deeply, and exhalation should occur before placing the
spacer in the mouth, not into it.
Question 9: Which action by the nurse best supports therapeutic communication when a
client expresses anxiety about an upcoming surgery?
A. Stating, "There's no need to worry; the surgeon is very experienced."
B. Asking, "What specifically about the surgery concerns you the most?"
C. Changing the subject to discuss postoperative pain management options.
D. Reassuring the client that many people undergo this procedure safely.
CORRECT ANSWER: B. Asking, "What specifically about the surgery concerns you the most?"
Rationale: Open-ended questions encourage clients to express feelings and concerns,
facilitating therapeutic communication and allowing the nurse to address specific fears. False
reassurance, changing the subject, or minimizing concerns blocks communication and fails to
address the client's emotional needs.
Question 10: A nurse is calculating the drip rate for an IV infusion of 1000 mL normal saline to
be administered over 8 hours using tubing with a drop factor of 15 gtt/mL. What is the
correct drip rate in drops per minute?
A. 21 gtt/min
B. 31 gtt/min
C. 42 gtt/min
D. 63 gtt/min
CORRECT ANSWER: B. 31 gtt/min
Rationale: The formula is (Volume in mL × Drop factor) ÷ Time in minutes. Calculation: (1000 mL
× 15 gtt/mL) ÷ (8 hours × 60 min) = 15,000 ÷ 480 = 31.25, rounded to 31 gtt/min. Accurate drip
rate calculation ensures safe and timely fluid administration.
Question 11: Which finding is the earliest indicator of hypoxia in an adult client?
A. Cyanosis of the lips and nail beds
B. Restlessness and confusion
C. Bradycardia and hypotension
D. Use of accessory muscles for breathing
CORRECT ANSWER: B. Restlessness and confusion
Rationale: Restlessness, anxiety, and confusion are early neurological signs of hypoxia due to
the brain's high oxygen demand. Cyanosis is a late sign, bradycardia and hypotension occur in
