Fundamentals of Nursing NCLEX Practice
Exam Set 4 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2025/2026 Q&A | Instant
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1. Which nursing action best demonstrates the principle of
accountability?
A. Delegating tasks to unlicensed assistive personnel
B. Documenting care provided accurately
C. Asking another nurse to complete an assessment
D. Following a physician’s order without question
Answer: B
Accurate documentation reflects responsibility and accountability for
nursing actions.
2. A nurse is caring for a client with impaired mobility. Which
intervention best prevents pressure injuries?
A. Massaging reddened areas
B. Repositioning the client every 2 hours
C. Applying heat to bony prominences
D. Limiting fluid intake
Answer: B
Frequent repositioning relieves pressure and promotes circulation,
preventing skin breakdown.
3. Which vital sign finding should the nurse report immediately?
,A. Temperature 37.5°C (99.5°F)
B. Pulse 98 beats/min
C. Respiratory rate 8 breaths/min
D. Blood pressure 130/82 mmHg
Answer: C
Respiratory depression is life-threatening and requires immediate
intervention.
4. The nurse is teaching a client about hand hygiene. Which
statement indicates understanding?
A. “I should wash my hands for at least 5 seconds.”
B. “Hand sanitizer works even if my hands are visibly dirty.”
C. “I should wash my hands before and after patient contact.”
D. “Gloves eliminate the need for handwashing.”
Answer: C
Hand hygiene before and after contact is essential to prevent
infection.
5. Which task is appropriate for the nurse to delegate to a nursing
assistant?
A. Initial patient assessment
B. Teaching a client how to use an incentive spirometer
C. Measuring intake and output
D. Administering oral medications
Answer: C
Measuring intake and output is a routine task appropriate for
delegation.
6. Which position is best for a client experiencing dyspnea?
,A. Supine
B. Prone
C. Fowler’s
D. Trendelenburg
Answer: C
Fowler’s position promotes lung expansion and improves breathing.
7. A nurse notes redness over a client’s sacrum that does not
blanch. How should this be documented?
A. Stage 2 pressure injury
B. Stage 3 pressure injury
C. Stage 1 pressure injury
D. Skin tear
Answer: C
Non-blanchable redness with intact skin indicates a Stage 1 pressure
injury.
8. Which client is at greatest risk for infection?
A. A 20-year-old postoperative client
B. A 45-year-old client with hypertension
C. A 70-year-old client with diabetes
D. A 30-year-old client with a fracture
Answer: C
Diabetes and advanced age impair immune response and wound
healing.
9. Which action violates the nurse’s ethical principle of autonomy?
, A. Providing informed consent information
B. Respecting a client’s refusal of treatment
C. Withholding treatment options
D. Supporting client decision-making
Answer: C
Withholding information prevents the client from making informed
decisions.
10. A client is placed in restraints. Which nursing action is required?
A. Remove restraints every 8 hours
B. Document alternatives tried before restraint use
C. Tie restraints to side rails
D. Obtain a PRN prescription
Answer: B
Documentation of less restrictive measures is legally and ethically
required.
11. Which pulse site is best for assessing circulation in the foot?
A. Radial
B. Popliteal
C. Posterior tibial
D. Brachial
Answer: C
The posterior tibial pulse reflects circulation to the foot.
12. Which finding indicates dehydration?
A. Bounding pulse
B. Decreased skin turgor
Exam Set 4 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2025/2026 Q&A | Instant
Download Pdf
1. Which nursing action best demonstrates the principle of
accountability?
A. Delegating tasks to unlicensed assistive personnel
B. Documenting care provided accurately
C. Asking another nurse to complete an assessment
D. Following a physician’s order without question
Answer: B
Accurate documentation reflects responsibility and accountability for
nursing actions.
2. A nurse is caring for a client with impaired mobility. Which
intervention best prevents pressure injuries?
A. Massaging reddened areas
B. Repositioning the client every 2 hours
C. Applying heat to bony prominences
D. Limiting fluid intake
Answer: B
Frequent repositioning relieves pressure and promotes circulation,
preventing skin breakdown.
3. Which vital sign finding should the nurse report immediately?
,A. Temperature 37.5°C (99.5°F)
B. Pulse 98 beats/min
C. Respiratory rate 8 breaths/min
D. Blood pressure 130/82 mmHg
Answer: C
Respiratory depression is life-threatening and requires immediate
intervention.
4. The nurse is teaching a client about hand hygiene. Which
statement indicates understanding?
A. “I should wash my hands for at least 5 seconds.”
B. “Hand sanitizer works even if my hands are visibly dirty.”
C. “I should wash my hands before and after patient contact.”
D. “Gloves eliminate the need for handwashing.”
Answer: C
Hand hygiene before and after contact is essential to prevent
infection.
5. Which task is appropriate for the nurse to delegate to a nursing
assistant?
A. Initial patient assessment
B. Teaching a client how to use an incentive spirometer
C. Measuring intake and output
D. Administering oral medications
Answer: C
Measuring intake and output is a routine task appropriate for
delegation.
6. Which position is best for a client experiencing dyspnea?
,A. Supine
B. Prone
C. Fowler’s
D. Trendelenburg
Answer: C
Fowler’s position promotes lung expansion and improves breathing.
7. A nurse notes redness over a client’s sacrum that does not
blanch. How should this be documented?
A. Stage 2 pressure injury
B. Stage 3 pressure injury
C. Stage 1 pressure injury
D. Skin tear
Answer: C
Non-blanchable redness with intact skin indicates a Stage 1 pressure
injury.
8. Which client is at greatest risk for infection?
A. A 20-year-old postoperative client
B. A 45-year-old client with hypertension
C. A 70-year-old client with diabetes
D. A 30-year-old client with a fracture
Answer: C
Diabetes and advanced age impair immune response and wound
healing.
9. Which action violates the nurse’s ethical principle of autonomy?
, A. Providing informed consent information
B. Respecting a client’s refusal of treatment
C. Withholding treatment options
D. Supporting client decision-making
Answer: C
Withholding information prevents the client from making informed
decisions.
10. A client is placed in restraints. Which nursing action is required?
A. Remove restraints every 8 hours
B. Document alternatives tried before restraint use
C. Tie restraints to side rails
D. Obtain a PRN prescription
Answer: B
Documentation of less restrictive measures is legally and ethically
required.
11. Which pulse site is best for assessing circulation in the foot?
A. Radial
B. Popliteal
C. Posterior tibial
D. Brachial
Answer: C
The posterior tibial pulse reflects circulation to the foot.
12. Which finding indicates dehydration?
A. Bounding pulse
B. Decreased skin turgor
