NUR 114 Exam 4 – Nursing Fundamentals
2026 NCLEX-Style Questions Complete 300-
Question Exam
1. A nurse is caring for a client who has a nasogastric (NG) tube set to
continuous suction. Which finding indicates the tube may be displaced?
A. Gastric pH of 4
B. Client reports nausea
C. Absence of gastric drainage for 2 hours
D. Bowel sounds present in all four quadrants
Answer: C
Rationale: Absence of drainage with continuous suction suggests tube
displacement or blockage. Gastric pH ≤4 is normal. Nausea alone is not
specific.
2. A client with chronic kidney disease (CKD) has a potassium level of 6.1
mEq/L. Which intervention should the nurse implement first?
A. Encourage bananas and oranges
B. Prepare for dialysis or potassium-lowering medication
C. Restrict oral fluids to 500 mL/day
D. Administer a potassium supplement
Answer: B
Rationale: Hyperkalemia >6.0 is life-threatening (cardiac arrest risk).
Immediate treatment required.
3. A nurse is teaching a client about a clear liquid diet. Which item is
allowed?
A. Cream of wheat
B. Orange juice with pulp
,C. Chicken broth
D. Milkshake
Answer: C
Rationale: Clear liquids include broth, clear juice (no pulp), gelatin, water,
tea, coffee. No dairy or solids.
4. A client is 2 hours post-operative from abdominal surgery. Which finding
should the nurse report to the provider immediately?
A. Pain rated 5/10
B. Serosanguineous drainage on dressing
C. Heart rate 110 bpm and blood pressure 90/60 mm Hg
D. Urine output 40 mL in the past hour
Answer: C
Rationale: Tachycardia + hypotension may indicate hemorrhage or shock.
Report immediately.
5. A nurse is caring for a client with a new colostomy. Which statement by
the client indicates a need for further teaching?
A. “I will cut the wafer opening 1/8 inch larger than my stoma.”
B. “I can shower with my pouch on or off.”
C. “I will change my pouch every day to prevent infection.”
D. “My stoma should be pink and moist.”
Answer: C
Rationale: Pouches should be changed every 3–7 days or when leaking. Daily
changes cause skin breakdown.
6. A client with a history of falls is taking lorazepam (Ativan) for anxiety.
Which instruction is most important?
A. Take with food
B. Avoid alcohol and rise slowly from sitting
,C. Take in the morning
D. Double the dose if anxious
Answer: B
Rationale: Lorazepam causes sedation and orthostatic hypotension → fall
risk. Avoid alcohol; rise slowly. Never double dose.
7. A nurse is assessing a client’s IV site. Which finding suggests infiltration?
A. Redness and warmth along the vein
B. Edema, pallor, and coolness around the site
C. Purulent drainage at insertion site
D. Blood return on flush
Answer: B
Rationale: Infiltration = fluid leaking into tissue → swelling, pallor, coolness.
Redness/warmth = phlebitis.
8. A client with heart failure has a prescription for a 2-gram sodium diet.
Which food choice is appropriate?
A. Canned chicken noodle soup
B. Deli turkey sandwich
C. Fresh baked salmon with lemon
D. Frozen lasagna
Answer: C
Rationale: Fresh salmon is naturally low in sodium. Canned, deli, and frozen
foods are high in sodium.
9. A nurse is suctioning a client’s tracheostomy. Which action is correct?
A. Apply suction while inserting the catheter
B. Suction for 20–30 seconds each pass
C. Hyperoxygenate before and between suction passes
D. Use the same catheter for multiple passes
, Answer: C
Rationale: Hyperoxygenation prevents hypoxia. Suction only during
withdrawal (max 10–15 seconds). Never reuse catheter.
10. A client with a closed head injury has a Glasgow Coma Scale (GCS) score
of 9. The nurse should:
A. Document as normal
B. Prepare for possible intubation (moderate brain injury)
C. Continue routine monitoring only
D. Discontinue neurological checks
Answer: B
Rationale: GCS 9–12 indicates moderate brain injury; airway protection may
be needed. GCS ≤8 requires intubation.
11. 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 finding
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.
12. 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
2026 NCLEX-Style Questions Complete 300-
Question Exam
1. A nurse is caring for a client who has a nasogastric (NG) tube set to
continuous suction. Which finding indicates the tube may be displaced?
A. Gastric pH of 4
B. Client reports nausea
C. Absence of gastric drainage for 2 hours
D. Bowel sounds present in all four quadrants
Answer: C
Rationale: Absence of drainage with continuous suction suggests tube
displacement or blockage. Gastric pH ≤4 is normal. Nausea alone is not
specific.
2. A client with chronic kidney disease (CKD) has a potassium level of 6.1
mEq/L. Which intervention should the nurse implement first?
A. Encourage bananas and oranges
B. Prepare for dialysis or potassium-lowering medication
C. Restrict oral fluids to 500 mL/day
D. Administer a potassium supplement
Answer: B
Rationale: Hyperkalemia >6.0 is life-threatening (cardiac arrest risk).
Immediate treatment required.
3. A nurse is teaching a client about a clear liquid diet. Which item is
allowed?
A. Cream of wheat
B. Orange juice with pulp
,C. Chicken broth
D. Milkshake
Answer: C
Rationale: Clear liquids include broth, clear juice (no pulp), gelatin, water,
tea, coffee. No dairy or solids.
4. A client is 2 hours post-operative from abdominal surgery. Which finding
should the nurse report to the provider immediately?
A. Pain rated 5/10
B. Serosanguineous drainage on dressing
C. Heart rate 110 bpm and blood pressure 90/60 mm Hg
D. Urine output 40 mL in the past hour
Answer: C
Rationale: Tachycardia + hypotension may indicate hemorrhage or shock.
Report immediately.
5. A nurse is caring for a client with a new colostomy. Which statement by
the client indicates a need for further teaching?
A. “I will cut the wafer opening 1/8 inch larger than my stoma.”
B. “I can shower with my pouch on or off.”
C. “I will change my pouch every day to prevent infection.”
D. “My stoma should be pink and moist.”
Answer: C
Rationale: Pouches should be changed every 3–7 days or when leaking. Daily
changes cause skin breakdown.
6. A client with a history of falls is taking lorazepam (Ativan) for anxiety.
Which instruction is most important?
A. Take with food
B. Avoid alcohol and rise slowly from sitting
,C. Take in the morning
D. Double the dose if anxious
Answer: B
Rationale: Lorazepam causes sedation and orthostatic hypotension → fall
risk. Avoid alcohol; rise slowly. Never double dose.
7. A nurse is assessing a client’s IV site. Which finding suggests infiltration?
A. Redness and warmth along the vein
B. Edema, pallor, and coolness around the site
C. Purulent drainage at insertion site
D. Blood return on flush
Answer: B
Rationale: Infiltration = fluid leaking into tissue → swelling, pallor, coolness.
Redness/warmth = phlebitis.
8. A client with heart failure has a prescription for a 2-gram sodium diet.
Which food choice is appropriate?
A. Canned chicken noodle soup
B. Deli turkey sandwich
C. Fresh baked salmon with lemon
D. Frozen lasagna
Answer: C
Rationale: Fresh salmon is naturally low in sodium. Canned, deli, and frozen
foods are high in sodium.
9. A nurse is suctioning a client’s tracheostomy. Which action is correct?
A. Apply suction while inserting the catheter
B. Suction for 20–30 seconds each pass
C. Hyperoxygenate before and between suction passes
D. Use the same catheter for multiple passes
, Answer: C
Rationale: Hyperoxygenation prevents hypoxia. Suction only during
withdrawal (max 10–15 seconds). Never reuse catheter.
10. A client with a closed head injury has a Glasgow Coma Scale (GCS) score
of 9. The nurse should:
A. Document as normal
B. Prepare for possible intubation (moderate brain injury)
C. Continue routine monitoring only
D. Discontinue neurological checks
Answer: B
Rationale: GCS 9–12 indicates moderate brain injury; airway protection may
be needed. GCS ≤8 requires intubation.
11. 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 finding
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.
12. 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
