NURSING 101 EXAM 1 COMPREHENSIVE NCLEX-
STYLE EXAM PREP FOR NURSING STUDENTS
COMPLETE QUESTIONS WITH 100% VERIFIED
ANSWERS AND RATIONALES
Section 1: Fundamentals of Nursing (Questions 1–40)
1. A nurse is caring for a patient who has just been diagnosed with cancer. The
patient asks, "Why me?" Which response by the nurse is most therapeutic?
✔ "You're wondering why this happened to you?"
Rationale: This response uses reflection, validating the patient's emotion and
encouraging further expression. Option A offers false reassurance. Option B
dismisses the patient's feelings. Option D imposes the nurse's personal beliefs.
2. Which patient statement indicates an accurate understanding of advance
directives?
✔ I can change my advance directives at any time."
Rationale: Advance directives are legally revocable and modifiable as long as the
patient is competent. Option B is incorrect because changes are allowed. Option C
is false; advance directives are for any adult. Option D is false; family cannot
override a patient's documented wishes.
3. A nurse is preparing to insert an indwelling urinary catheter. Which technique
is correct for maintaining sterility?
,A. Clean gloves and sterile lubricant only
✔ B. Use sterile gloves, a sterile drape, and sterile lubricant
C. Clean gloves, clean drape, and antiseptic solution
D. Sterile gloves without a drape if the patient is male
Rationale: Indwelling catheter insertion requires a sterile field including sterile
gloves, sterile drape, and sterile lubricant to prevent urinary tract infections.
Option A breaks sterility. Option C uses clean instead of sterile items. Option D
omits the drape, increasing infection risk.
4. A nurse hears a fire alarm and sees smoke coming from a patient's room.
What is the priority action?
A. Pull the fire alarm
B. Evacuate the patient from the room
✔ C. Rescue the patient immediately
D. Attempt to extinguish the fire
Rationale: The RACE protocol prioritizes Rescue first (Remove patients from
danger), then Alarm, Confine, Extinguish. Option C aligns with Rescue. Options A
and D come after rescue. Option B uses "evacuate" but rescue is the immediate
priority action.
5. A patient with a nasogastric tube to low intermittent suction has a
prescription for irrigation every 4 hours. Which action by the nurse is correct?
A. Use sterile water for irrigation
✔ B. Use normal saline for irrigation
C. Use tap water for irrigation
D. Use distilled water for irrigation
,Rationale: Normal saline is used for NG tube irrigation to prevent electrolyte
imbalances, especially with continuous or intermittent suction. Tap or distilled
water can cause hyponatremia. Sterile water is not typically used.
6. A nurse is teaching a patient about a low-sodium diet. Which food choice
indicates understanding?
A. Canned vegetable soup
B. Deli turkey sandwich
✔ C. Baked chicken breast with steamed broccoli
D. Pickles and olives
Rationale: Fresh baked chicken and steamed broccoli are naturally low in sodium.
Canned soup, deli meats, pickles, and olives are high in sodium due to processing
and preservatives.
7. A nurse is assessing a patient's peripheral IV site. Which finding requires
immediate discontinuation of the IV?
A. Slight edema around the site
B. Warmth and redness at the insertion site
C. A small amount of dried blood under the dressing
✔ D. Purulent drainage at the insertion site
Rationale: Purulent drainage indicates infection, requiring immediate IV removal
and culture. Slight edema may be infiltration; warmth/redness may be phlebitis;
dried blood is common. All require monitoring, but purulent drainage is an
emergency.
8. A nurse is performing hand hygiene before patient care. Which action is
correct?
, A. Use hand sanitizer if hands are visibly soiled
B. Wash hands for 5 seconds with soap and water
✔ C. Use soap and water for at least 15 seconds after visible soiling
D. Rinse hands with water only before donning gloves
Rationale: CDC guidelines require soap and water for at least 15 seconds when
hands are visibly soiled. Hand sanitizer is not effective on visible dirt. Five seconds
is insufficient. Rinsing alone does not remove pathogens.
9. A patient is on fall precautions. Which intervention is most important?
A. Raise all side rails completely
B. Keep the call light out of reach to prevent wandering
✔ C. Keep the bed in the lowest position with wheels locked
D. Encourage the patient to stay in bed at all times
Rationale: The lowest bed position with locked wheels reduces injury risk from
falls. Full side rails are considered a restraint and increase injury risk. Call light
must be within reach. Encouraging bedrest immobility increases deconditioning.
10. A nurse is educating a patient about a new prescription for warfarin. Which
statement by the patient indicates a need for further teaching?
A. "I will avoid drinking alcohol."
B. "I will tell my dentist I take this medication."
✔ C. "I will eat more green leafy vegetables like spinach and kale."
D. "I will watch for bleeding gums or easy bruising."
Rationale: Green leafy vegetables are high in vitamin K, which antagonizes
warfarin's effects. Consistent intake is allowed, but increasing intake reduces INR
and therapeutic effect. Options A, B, and D are correct safety measures.
STYLE EXAM PREP FOR NURSING STUDENTS
COMPLETE QUESTIONS WITH 100% VERIFIED
ANSWERS AND RATIONALES
Section 1: Fundamentals of Nursing (Questions 1–40)
1. A nurse is caring for a patient who has just been diagnosed with cancer. The
patient asks, "Why me?" Which response by the nurse is most therapeutic?
✔ "You're wondering why this happened to you?"
Rationale: This response uses reflection, validating the patient's emotion and
encouraging further expression. Option A offers false reassurance. Option B
dismisses the patient's feelings. Option D imposes the nurse's personal beliefs.
2. Which patient statement indicates an accurate understanding of advance
directives?
✔ I can change my advance directives at any time."
Rationale: Advance directives are legally revocable and modifiable as long as the
patient is competent. Option B is incorrect because changes are allowed. Option C
is false; advance directives are for any adult. Option D is false; family cannot
override a patient's documented wishes.
3. A nurse is preparing to insert an indwelling urinary catheter. Which technique
is correct for maintaining sterility?
,A. Clean gloves and sterile lubricant only
✔ B. Use sterile gloves, a sterile drape, and sterile lubricant
C. Clean gloves, clean drape, and antiseptic solution
D. Sterile gloves without a drape if the patient is male
Rationale: Indwelling catheter insertion requires a sterile field including sterile
gloves, sterile drape, and sterile lubricant to prevent urinary tract infections.
Option A breaks sterility. Option C uses clean instead of sterile items. Option D
omits the drape, increasing infection risk.
4. A nurse hears a fire alarm and sees smoke coming from a patient's room.
What is the priority action?
A. Pull the fire alarm
B. Evacuate the patient from the room
✔ C. Rescue the patient immediately
D. Attempt to extinguish the fire
Rationale: The RACE protocol prioritizes Rescue first (Remove patients from
danger), then Alarm, Confine, Extinguish. Option C aligns with Rescue. Options A
and D come after rescue. Option B uses "evacuate" but rescue is the immediate
priority action.
5. A patient with a nasogastric tube to low intermittent suction has a
prescription for irrigation every 4 hours. Which action by the nurse is correct?
A. Use sterile water for irrigation
✔ B. Use normal saline for irrigation
C. Use tap water for irrigation
D. Use distilled water for irrigation
,Rationale: Normal saline is used for NG tube irrigation to prevent electrolyte
imbalances, especially with continuous or intermittent suction. Tap or distilled
water can cause hyponatremia. Sterile water is not typically used.
6. A nurse is teaching a patient about a low-sodium diet. Which food choice
indicates understanding?
A. Canned vegetable soup
B. Deli turkey sandwich
✔ C. Baked chicken breast with steamed broccoli
D. Pickles and olives
Rationale: Fresh baked chicken and steamed broccoli are naturally low in sodium.
Canned soup, deli meats, pickles, and olives are high in sodium due to processing
and preservatives.
7. A nurse is assessing a patient's peripheral IV site. Which finding requires
immediate discontinuation of the IV?
A. Slight edema around the site
B. Warmth and redness at the insertion site
C. A small amount of dried blood under the dressing
✔ D. Purulent drainage at the insertion site
Rationale: Purulent drainage indicates infection, requiring immediate IV removal
and culture. Slight edema may be infiltration; warmth/redness may be phlebitis;
dried blood is common. All require monitoring, but purulent drainage is an
emergency.
8. A nurse is performing hand hygiene before patient care. Which action is
correct?
, A. Use hand sanitizer if hands are visibly soiled
B. Wash hands for 5 seconds with soap and water
✔ C. Use soap and water for at least 15 seconds after visible soiling
D. Rinse hands with water only before donning gloves
Rationale: CDC guidelines require soap and water for at least 15 seconds when
hands are visibly soiled. Hand sanitizer is not effective on visible dirt. Five seconds
is insufficient. Rinsing alone does not remove pathogens.
9. A patient is on fall precautions. Which intervention is most important?
A. Raise all side rails completely
B. Keep the call light out of reach to prevent wandering
✔ C. Keep the bed in the lowest position with wheels locked
D. Encourage the patient to stay in bed at all times
Rationale: The lowest bed position with locked wheels reduces injury risk from
falls. Full side rails are considered a restraint and increase injury risk. Call light
must be within reach. Encouraging bedrest immobility increases deconditioning.
10. A nurse is educating a patient about a new prescription for warfarin. Which
statement by the patient indicates a need for further teaching?
A. "I will avoid drinking alcohol."
B. "I will tell my dentist I take this medication."
✔ C. "I will eat more green leafy vegetables like spinach and kale."
D. "I will watch for bleeding gums or easy bruising."
Rationale: Green leafy vegetables are high in vitamin K, which antagonizes
warfarin's effects. Consistent intake is allowed, but increasing intake reduces INR
and therapeutic effect. Options A, B, and D are correct safety measures.
