**Title:** **Foundations of Nursing Excellence: NCLEX-
RN Fundamentals & Safety Review**
---
### Question 1 of 99
A nurse is preparing to insert an indwelling urinary catheter for a female client. Which action maintains
sterile technique?
A) Open the catheter kit after donning sterile gloves.
B) Clean each labial fold with a single cotton ball using a back-and-forth motion.
C) Separate the labia with the non-dominant hand and keep it in place throughout.
D) Insert the catheter until urine flows, then advance another 5-7 inches.
💫RATIONALE✔️✔️: Non-dominant hand separates labia and remains in place; dominant hand handles
catheter (C). Clean front-to-back. Advance 2-3 inches after urine flow.
💫ANSWER✔️✔️: C) Separate the labia with the non-dominant hand and keep it in place throughout.
---
### Question 2 of 99
A nurse is caring for a client with a nasogastric (NG) tube set to low intermittent suction. The client asks,
"Why do I have this tube?" Which response should the nurse provide?
A) "The tube gives you liquid nutrition while you cannot eat."
,B) "It keeps your stomach empty to prevent nausea and vomiting."
C) "The tube removes stomach contents to prevent aspiration."
D) "It decompresses your stomach by removing gas and fluid."
💫RATIONALE✔️✔️: NG tube to suction decompresses the stomach by removing gas and fluid (D),
reducing distension and risk of vomiting/aspiration.
💫ANSWER✔️✔️: D) "It decompresses your stomach by removing gas and fluid."
---
### Question 3 of 99
**Select-All-That-Apply (SATA):** A nurse is providing discharge teaching to a client going home with a
new colostomy. Which instructions should the nurse include? (Select all that apply.)
A) Change the ostomy pouch immediately when it becomes one-third full.
B) Clean the peristomal skin with mild soap and water.
C) Cut the wafer opening slightly larger than the stoma.
D) Report any dark purple or black discoloration of the stoma.
E) Apply lotion to the skin around the stoma to prevent irritation.
💫RATIONALE✔️✔️: Clean with mild soap/water (B), cut wafer slightly larger (C), report stoma color
changes (D) correct. Pouch emptied when 1/3-1/2 full, not changed. Avoid lotions (prevent adhesion).
💫ANSWER✔️✔️: B, C, D
---
### Question 4 of 99
,A nurse is administering an intramuscular (IM) injection of the hepatitis B vaccine to an adult client.
Which site is most appropriate?
A) Ventrogluteal
B) Dorsogluteal
C) Deltoid
D) Vastus lateralis
💫RATIONALE✔️✔️: Deltoid muscle (C) is the preferred site for IM vaccines in adults due to smaller
volume and faster absorption.
💫ANSWER✔️✔️: C) Deltoid
---
### Question 5 of 99
A nurse is preparing to administer an enteral feeding through a nasogastric tube. Which action should
the nurse take to verify tube placement before feeding?
A) Auscultate for air insufflated into the stomach.
B) Measure the pH of aspirated gastric contents.
C) Check the external length of the tube from the nares.
D) Flush the tube with 30 mL of water and observe for coughing.
💫RATIONALE✔️✔️: pH testing of aspirated contents (B) is most reliable (gastric pH 1-4). Auscultation is
unreliable. Flushing does not confirm placement.
💫ANSWER✔️✔️: B) Measure the pH of aspirated gastric contents.
---
, ### Question 6 of 99
A nurse is caring for a client with a new prescription for a clear liquid diet. Which item should the nurse
offer?
A) Vanilla ice cream
B) Cream of chicken soup
C) Apple juice
D) Orange sherbet
💫RATIONALE✔️✔️: Apple juice (C) is a clear liquid. Ice cream, cream soups, and sherbet are not clear
liquids.
💫ANSWER✔️✔️: C) Apple juice
---
### Question 7 of 99
**Select-All-That-Apply (SATA):** A nurse is providing education to a client about deep breathing and
coughing exercises after surgery. Which instructions should the nurse include? (Select all that apply.)
A) Splint the incision with a pillow or folded blanket.
B) Take three deep breaths before each cough.
C) Cough deeply from your throat, not your chest.
D) Repeat the exercises every hour while awake.
E) Hold your breath for 10 seconds after each deep breath.
💫RATIONALE✔️✔️: Splinting (A), several deep breaths before coughing (B), hourly exercises (D) correct.
Cough deep from chest, not throat. Hold breath for 2-3 seconds, not 10.
💫ANSWER✔️✔️: A, B, D
RN Fundamentals & Safety Review**
---
### Question 1 of 99
A nurse is preparing to insert an indwelling urinary catheter for a female client. Which action maintains
sterile technique?
A) Open the catheter kit after donning sterile gloves.
B) Clean each labial fold with a single cotton ball using a back-and-forth motion.
C) Separate the labia with the non-dominant hand and keep it in place throughout.
D) Insert the catheter until urine flows, then advance another 5-7 inches.
💫RATIONALE✔️✔️: Non-dominant hand separates labia and remains in place; dominant hand handles
catheter (C). Clean front-to-back. Advance 2-3 inches after urine flow.
💫ANSWER✔️✔️: C) Separate the labia with the non-dominant hand and keep it in place throughout.
---
### Question 2 of 99
A nurse is caring for a client with a nasogastric (NG) tube set to low intermittent suction. The client asks,
"Why do I have this tube?" Which response should the nurse provide?
A) "The tube gives you liquid nutrition while you cannot eat."
,B) "It keeps your stomach empty to prevent nausea and vomiting."
C) "The tube removes stomach contents to prevent aspiration."
D) "It decompresses your stomach by removing gas and fluid."
💫RATIONALE✔️✔️: NG tube to suction decompresses the stomach by removing gas and fluid (D),
reducing distension and risk of vomiting/aspiration.
💫ANSWER✔️✔️: D) "It decompresses your stomach by removing gas and fluid."
---
### Question 3 of 99
**Select-All-That-Apply (SATA):** A nurse is providing discharge teaching to a client going home with a
new colostomy. Which instructions should the nurse include? (Select all that apply.)
A) Change the ostomy pouch immediately when it becomes one-third full.
B) Clean the peristomal skin with mild soap and water.
C) Cut the wafer opening slightly larger than the stoma.
D) Report any dark purple or black discoloration of the stoma.
E) Apply lotion to the skin around the stoma to prevent irritation.
💫RATIONALE✔️✔️: Clean with mild soap/water (B), cut wafer slightly larger (C), report stoma color
changes (D) correct. Pouch emptied when 1/3-1/2 full, not changed. Avoid lotions (prevent adhesion).
💫ANSWER✔️✔️: B, C, D
---
### Question 4 of 99
,A nurse is administering an intramuscular (IM) injection of the hepatitis B vaccine to an adult client.
Which site is most appropriate?
A) Ventrogluteal
B) Dorsogluteal
C) Deltoid
D) Vastus lateralis
💫RATIONALE✔️✔️: Deltoid muscle (C) is the preferred site for IM vaccines in adults due to smaller
volume and faster absorption.
💫ANSWER✔️✔️: C) Deltoid
---
### Question 5 of 99
A nurse is preparing to administer an enteral feeding through a nasogastric tube. Which action should
the nurse take to verify tube placement before feeding?
A) Auscultate for air insufflated into the stomach.
B) Measure the pH of aspirated gastric contents.
C) Check the external length of the tube from the nares.
D) Flush the tube with 30 mL of water and observe for coughing.
💫RATIONALE✔️✔️: pH testing of aspirated contents (B) is most reliable (gastric pH 1-4). Auscultation is
unreliable. Flushing does not confirm placement.
💫ANSWER✔️✔️: B) Measure the pH of aspirated gastric contents.
---
, ### Question 6 of 99
A nurse is caring for a client with a new prescription for a clear liquid diet. Which item should the nurse
offer?
A) Vanilla ice cream
B) Cream of chicken soup
C) Apple juice
D) Orange sherbet
💫RATIONALE✔️✔️: Apple juice (C) is a clear liquid. Ice cream, cream soups, and sherbet are not clear
liquids.
💫ANSWER✔️✔️: C) Apple juice
---
### Question 7 of 99
**Select-All-That-Apply (SATA):** A nurse is providing education to a client about deep breathing and
coughing exercises after surgery. Which instructions should the nurse include? (Select all that apply.)
A) Splint the incision with a pillow or folded blanket.
B) Take three deep breaths before each cough.
C) Cough deeply from your throat, not your chest.
D) Repeat the exercises every hour while awake.
E) Hold your breath for 10 seconds after each deep breath.
💫RATIONALE✔️✔️: Splinting (A), several deep breaths before coughing (B), hourly exercises (D) correct.
Cough deep from chest, not throat. Hold breath for 2-3 seconds, not 10.
💫ANSWER✔️✔️: A, B, D
