NUR 114 Exam 1 – Nursing Fundamentals 2026
NCLEX-Style Questions ABCD Format | Answers &
Rationales
1. A nurse is caring for a client who has just been admitted with pneumonia. Which
assessment finding requires immediate intervention?
A. Temperature of 100.4°F (38°C)
B. Oxygen saturation of 88% on room air
C. Productive cough with green sputum
D. Respiratory rate of 24 breaths per minute
Answer: B
Rationale: SpO2 of 88% indicates hypoxemia – an airway/breathing priority. Fever,
productive cough, and tachypnea are expected with pneumonia but do not require
immediate intervention before oxygenation.
2. A nurse is teaching a client with a new diagnosis of hypertension about the DASH diet.
Which food choice is most appropriate?
A. Bacon and eggs with white toast
B. Grilled salmon with steamed broccoli and brown rice
C. Canned vegetable soup with saltine crackers
D. Ham and cheese sandwich with pickles
Answer: B
Rationale: The DASH diet emphasizes fruits, vegetables, whole grains, lean protein, and
low sodium. Grilled salmon, broccoli, and brown rice fit this pattern.
3. A client with diabetes has a blood glucose of 45 mg/dL and is unconscious. What
should the nurse do first?
A. Give 4 oz of orange juice orally
B. Administer glucagon 1 mg IM or subcutaneously
C. Insert an IV line and give 50% dextrose
D. Call the provider
,Answer: B
Rationale: Glucagon IM/SQ raises blood glucose in an unconscious client. Oral
administration is unsafe. IV dextrose requires IV access, which takes time.
4. A nurse is caring for a client with an indwelling urinary catheter. Which action is most
important to prevent catheter-associated urinary tract infection (CAUTI)?
A. Change the catheter every 24 hours
B. Irrigate the catheter daily with normal saline
C. Keep the drainage bag below the level of the bladder
D. Empty the drainage bag every 2 hours
Answer: C
Rationale: Keeping the drainage bag below bladder level prevents backflow of urine.
Routine catheter changes and irrigations increase infection risk.
5. A client with heart failure is prescribed furosemide 40 mg IV. Which laboratory value
should the nurse monitor most closely?
A. Hemoglobin
B. Potassium
C. Platelets
D. Calcium
Answer: B
Rationale: Furosemide (loop diuretic) causes potassium wasting → hypokalemia risk.
6. A nurse is assessing a client's surgical wound on post-operative day 2. Which finding
should be reported to the provider?
A. Serosanguineous drainage on the dressing
B. Edges well approximated
C. Greenish drainage with a foul odor
D. Mild tenderness to palpation
Answer: C
Rationale: Greenish, foul-smelling drainage indicates purulent drainage from infection.
Serosanguineous drainage and mild tenderness are expected.
,7. A client with a new colostomy asks about pouch care. How often should the pouch be
changed?
A. Every day
B. Every 3–7 days or when leaking
C. Every 12 hours
D. Twice per week only
Answer: B
Rationale: Pouches can last 3–7 days if the seal is intact. Frequent changes cause skin
breakdown.
8. A nurse is administering digoxin. The client's apical pulse is 52 bpm. What should the
nurse do?
A. Administer the medication as ordered
B. Hold the dose and notify the provider
C. Retake the pulse in 15 minutes
D. Give atropine before digoxin
Answer: B
Rationale: Digoxin is held for an apical pulse <60 bpm in adults (unless ordered
otherwise).
9. A client with a new tracheostomy has a pulse oximetry of 85% on room air. What
should the nurse do first?
A. Suction the tracheostomy
B. Apply oxygen at 2 L/min
C. Call a rapid response
D. Change the inner cannula
Answer: A
Rationale: Low SpO2 with a new tracheostomy is often due to a mucus plug. Suction first.
10. A nurse is caring for a client with a chest tube. The water seal chamber has continuous
bubbling. What should the nurse do?
A. Document as normal
B. Check for an air leak
, C. Clamp the chest tube immediately
D. Increase suction pressure
Answer: B
Rationale: Continuous bubbling indicates an air leak. Clamping can cause tension
pneumothorax.
11. A client with a history of falls is taking furosemide. Which instruction is most
important?
A. Take with food
B. Rise slowly from sitting to standing
C. Take at bedtime only
D. Increase potassium intake
Answer: B
Rationale: Furosemide causes orthostatic hypotension → fall risk. Rising slowly prevents
dizziness and falls.
12. A nurse is assessing a client's pain. The client has dementia and is grimacing and
guarding. The nurse should:
A. Assume no pain because the client cannot report it
B. Treat for pain based on behaviors
C. Wait for family to arrive
D. Give a placebo
Answer: B
Rationale: Non-verbal pain behaviors (grimacing, guarding) indicate pain. Treat
empirically.
13. A client with a new ileostomy asks about foods that thicken output. The nurse should
recommend:
A. Prune juice
B. Applesauce, bananas, and rice
C. Raw vegetables
D. Orange juice
NCLEX-Style Questions ABCD Format | Answers &
Rationales
1. A nurse is caring for a client who has just been admitted with pneumonia. Which
assessment finding requires immediate intervention?
A. Temperature of 100.4°F (38°C)
B. Oxygen saturation of 88% on room air
C. Productive cough with green sputum
D. Respiratory rate of 24 breaths per minute
Answer: B
Rationale: SpO2 of 88% indicates hypoxemia – an airway/breathing priority. Fever,
productive cough, and tachypnea are expected with pneumonia but do not require
immediate intervention before oxygenation.
2. A nurse is teaching a client with a new diagnosis of hypertension about the DASH diet.
Which food choice is most appropriate?
A. Bacon and eggs with white toast
B. Grilled salmon with steamed broccoli and brown rice
C. Canned vegetable soup with saltine crackers
D. Ham and cheese sandwich with pickles
Answer: B
Rationale: The DASH diet emphasizes fruits, vegetables, whole grains, lean protein, and
low sodium. Grilled salmon, broccoli, and brown rice fit this pattern.
3. A client with diabetes has a blood glucose of 45 mg/dL and is unconscious. What
should the nurse do first?
A. Give 4 oz of orange juice orally
B. Administer glucagon 1 mg IM or subcutaneously
C. Insert an IV line and give 50% dextrose
D. Call the provider
,Answer: B
Rationale: Glucagon IM/SQ raises blood glucose in an unconscious client. Oral
administration is unsafe. IV dextrose requires IV access, which takes time.
4. A nurse is caring for a client with an indwelling urinary catheter. Which action is most
important to prevent catheter-associated urinary tract infection (CAUTI)?
A. Change the catheter every 24 hours
B. Irrigate the catheter daily with normal saline
C. Keep the drainage bag below the level of the bladder
D. Empty the drainage bag every 2 hours
Answer: C
Rationale: Keeping the drainage bag below bladder level prevents backflow of urine.
Routine catheter changes and irrigations increase infection risk.
5. A client with heart failure is prescribed furosemide 40 mg IV. Which laboratory value
should the nurse monitor most closely?
A. Hemoglobin
B. Potassium
C. Platelets
D. Calcium
Answer: B
Rationale: Furosemide (loop diuretic) causes potassium wasting → hypokalemia risk.
6. A nurse is assessing a client's surgical wound on post-operative day 2. Which finding
should be reported to the provider?
A. Serosanguineous drainage on the dressing
B. Edges well approximated
C. Greenish drainage with a foul odor
D. Mild tenderness to palpation
Answer: C
Rationale: Greenish, foul-smelling drainage indicates purulent drainage from infection.
Serosanguineous drainage and mild tenderness are expected.
,7. A client with a new colostomy asks about pouch care. How often should the pouch be
changed?
A. Every day
B. Every 3–7 days or when leaking
C. Every 12 hours
D. Twice per week only
Answer: B
Rationale: Pouches can last 3–7 days if the seal is intact. Frequent changes cause skin
breakdown.
8. A nurse is administering digoxin. The client's apical pulse is 52 bpm. What should the
nurse do?
A. Administer the medication as ordered
B. Hold the dose and notify the provider
C. Retake the pulse in 15 minutes
D. Give atropine before digoxin
Answer: B
Rationale: Digoxin is held for an apical pulse <60 bpm in adults (unless ordered
otherwise).
9. A client with a new tracheostomy has a pulse oximetry of 85% on room air. What
should the nurse do first?
A. Suction the tracheostomy
B. Apply oxygen at 2 L/min
C. Call a rapid response
D. Change the inner cannula
Answer: A
Rationale: Low SpO2 with a new tracheostomy is often due to a mucus plug. Suction first.
10. A nurse is caring for a client with a chest tube. The water seal chamber has continuous
bubbling. What should the nurse do?
A. Document as normal
B. Check for an air leak
, C. Clamp the chest tube immediately
D. Increase suction pressure
Answer: B
Rationale: Continuous bubbling indicates an air leak. Clamping can cause tension
pneumothorax.
11. A client with a history of falls is taking furosemide. Which instruction is most
important?
A. Take with food
B. Rise slowly from sitting to standing
C. Take at bedtime only
D. Increase potassium intake
Answer: B
Rationale: Furosemide causes orthostatic hypotension → fall risk. Rising slowly prevents
dizziness and falls.
12. A nurse is assessing a client's pain. The client has dementia and is grimacing and
guarding. The nurse should:
A. Assume no pain because the client cannot report it
B. Treat for pain based on behaviors
C. Wait for family to arrive
D. Give a placebo
Answer: B
Rationale: Non-verbal pain behaviors (grimacing, guarding) indicate pain. Treat
empirically.
13. A client with a new ileostomy asks about foods that thicken output. The nurse should
recommend:
A. Prune juice
B. Applesauce, bananas, and rice
C. Raw vegetables
D. Orange juice
