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160 VERIFIED NCLEX FUNDAMENTALS OF NURSING
QUESTIONS 2025 | 100% CORRECT POTTER & PERRY TEST BANK
WITH RATIONALES – GUARANTEED PASS
A nurse is caring for a client who is scheduled for surgery and expresses
fear about not waking up afterward. What is the nurse’s best initial
response?
A. “I’ll notify the surgeon so they can reassure you.”
B. “You’ll be fine, the anesthesia team is very experienced.”
C. “Tell me more about your concerns regarding the surgery.”
D. “Try not to worry; many people have surgery every day.”
Correct Answer: C
Rationale: The nurse should use therapeutic communication to explore the
client’s feelings further. Open-ended responses like “Tell me more…”
encourage the client to express fears and allow the nurse to assess the
emotional and psychological needs. Reassurance and deflecting statements
may minimize the client’s valid concerns.
2. A nurse prepares to insert a urinary catheter and realizes the sterile
field has been contaminated. What should the nurse do next?
A. Proceed quickly to avoid delays
B. Continue and report the break after insertion
, 2
C. Replace the contaminated items and reestablish a sterile field
D. Ask another nurse to assist while continuing with the current supplies
Correct Answer: C
Rationale: A break in sterile technique compromises patient safety. The
nurse is ethically and legally obligated to stop the procedure, replace
contaminated equipment, and reestablish a sterile field to prevent infection.
3. A client with heart failure gains 2 pounds overnight. What is the
nurse’s first action?
A. Notify the healthcare provider immediately
B. Reassess the client’s dietary intake
C. Auscultate lung sounds for crackles
D. Document the weight gain and monitor again tomorrow
Correct Answer: C
Rationale: A sudden weight gain in a heart failure client suggests fluid
retention. The nurse should assess for clinical signs of worsening heart
failure, such as crackles in the lungs, which may indicate pulmonary
congestion, before notifying the provider.
4. The nurse is teaching a new graduate about prioritizing care. Which
client should the nurse see first?
A. A client requesting pain medication rated 7/10
B. A client with a blood glucose of 380 mg/dL
C. A client newly diagnosed with hypertension
D. A client experiencing shortness of breath
Correct Answer: D
Rationale: According to the ABCs (Airway, Breathing, Circulation), the
client with respiratory distress takes priority. While all clients need care,
shortness of breath may indicate hypoxia, which is an immediate threat to
life.
, 3
5. A nurse is reviewing a medication order that seems unusually high.
What is the most appropriate action?
A. Administer the dose as written
B. Hold the medication and notify the prescriber
C. Call the pharmacy for clarification
D. Ask another nurse if the dose seems safe
Correct Answer: B
Rationale: Nurses are responsible for ensuring medication safety. If a
dosage appears unsafe, the nurse must withhold the drug and contact the
provider. Administering an unsafe dose, even as ordered, could cause harm
and constitutes negligence.
6. Which of the following is an example of a measurable outcome
statement in a care plan?
A. “Client will feel less anxious after education.”
B. “Client will understand medication side effects.”
C. “Client will verbalize two coping strategies by the end of the shift.”
D. “Client’s pain will be under control.”
Correct Answer: C
Rationale: A measurable outcome uses specific, observable criteria.
“Verbalize two coping strategies” is clear and measurable. Statements like
“understand” or “feel” are too vague for evaluation.
7. Which action best demonstrates the nurse’s role as an advocate?
A. Asking the client’s family for input on treatment
B. Educating the client about treatment options and supporting their decision
C. Informing the client’s physician about the hospital’s policies
D. Encouraging the client to comply with prescribed treatments
, 4
Correct Answer: B
Rationale: Advocacy involves protecting and supporting a client’s right to
make informed decisions. Educating and respecting the client’s autonomy
reflects true advocacy. Encouraging compliance without addressing
concerns can be coercive.
8. The nurse is performing hand hygiene. Which action is correct?
A. Scrubbing the hands for at least 10 seconds
B. Using hot water and antibacterial soap
C. Keeping hands lower than elbows while rinsing
D. Using friction and washing for at least 20 seconds
Correct Answer: D
Rationale: Effective hand hygiene requires friction and washing for a
minimum of 20 seconds. Lukewarm water is preferred to avoid skin
irritation. Friction removes microorganisms, and proper time ensures
thorough cleansing.
9. A nurse notices a client’s IV site is red, swollen, and painful. What is
the most appropriate action?
A. Slow the infusion rate
B. Apply a warm compress and continue infusion
C. Stop the infusion and remove the IV
D. Elevate the arm and monitor
Correct Answer: C
Rationale: Redness, swelling, and pain indicate phlebitis or infiltration. The
nurse should stop the infusion and remove the IV to prevent tissue damage
and infection. Continuing the infusion can worsen complications.
160 VERIFIED NCLEX FUNDAMENTALS OF NURSING
QUESTIONS 2025 | 100% CORRECT POTTER & PERRY TEST BANK
WITH RATIONALES – GUARANTEED PASS
A nurse is caring for a client who is scheduled for surgery and expresses
fear about not waking up afterward. What is the nurse’s best initial
response?
A. “I’ll notify the surgeon so they can reassure you.”
B. “You’ll be fine, the anesthesia team is very experienced.”
C. “Tell me more about your concerns regarding the surgery.”
D. “Try not to worry; many people have surgery every day.”
Correct Answer: C
Rationale: The nurse should use therapeutic communication to explore the
client’s feelings further. Open-ended responses like “Tell me more…”
encourage the client to express fears and allow the nurse to assess the
emotional and psychological needs. Reassurance and deflecting statements
may minimize the client’s valid concerns.
2. A nurse prepares to insert a urinary catheter and realizes the sterile
field has been contaminated. What should the nurse do next?
A. Proceed quickly to avoid delays
B. Continue and report the break after insertion
, 2
C. Replace the contaminated items and reestablish a sterile field
D. Ask another nurse to assist while continuing with the current supplies
Correct Answer: C
Rationale: A break in sterile technique compromises patient safety. The
nurse is ethically and legally obligated to stop the procedure, replace
contaminated equipment, and reestablish a sterile field to prevent infection.
3. A client with heart failure gains 2 pounds overnight. What is the
nurse’s first action?
A. Notify the healthcare provider immediately
B. Reassess the client’s dietary intake
C. Auscultate lung sounds for crackles
D. Document the weight gain and monitor again tomorrow
Correct Answer: C
Rationale: A sudden weight gain in a heart failure client suggests fluid
retention. The nurse should assess for clinical signs of worsening heart
failure, such as crackles in the lungs, which may indicate pulmonary
congestion, before notifying the provider.
4. The nurse is teaching a new graduate about prioritizing care. Which
client should the nurse see first?
A. A client requesting pain medication rated 7/10
B. A client with a blood glucose of 380 mg/dL
C. A client newly diagnosed with hypertension
D. A client experiencing shortness of breath
Correct Answer: D
Rationale: According to the ABCs (Airway, Breathing, Circulation), the
client with respiratory distress takes priority. While all clients need care,
shortness of breath may indicate hypoxia, which is an immediate threat to
life.
, 3
5. A nurse is reviewing a medication order that seems unusually high.
What is the most appropriate action?
A. Administer the dose as written
B. Hold the medication and notify the prescriber
C. Call the pharmacy for clarification
D. Ask another nurse if the dose seems safe
Correct Answer: B
Rationale: Nurses are responsible for ensuring medication safety. If a
dosage appears unsafe, the nurse must withhold the drug and contact the
provider. Administering an unsafe dose, even as ordered, could cause harm
and constitutes negligence.
6. Which of the following is an example of a measurable outcome
statement in a care plan?
A. “Client will feel less anxious after education.”
B. “Client will understand medication side effects.”
C. “Client will verbalize two coping strategies by the end of the shift.”
D. “Client’s pain will be under control.”
Correct Answer: C
Rationale: A measurable outcome uses specific, observable criteria.
“Verbalize two coping strategies” is clear and measurable. Statements like
“understand” or “feel” are too vague for evaluation.
7. Which action best demonstrates the nurse’s role as an advocate?
A. Asking the client’s family for input on treatment
B. Educating the client about treatment options and supporting their decision
C. Informing the client’s physician about the hospital’s policies
D. Encouraging the client to comply with prescribed treatments
, 4
Correct Answer: B
Rationale: Advocacy involves protecting and supporting a client’s right to
make informed decisions. Educating and respecting the client’s autonomy
reflects true advocacy. Encouraging compliance without addressing
concerns can be coercive.
8. The nurse is performing hand hygiene. Which action is correct?
A. Scrubbing the hands for at least 10 seconds
B. Using hot water and antibacterial soap
C. Keeping hands lower than elbows while rinsing
D. Using friction and washing for at least 20 seconds
Correct Answer: D
Rationale: Effective hand hygiene requires friction and washing for a
minimum of 20 seconds. Lukewarm water is preferred to avoid skin
irritation. Friction removes microorganisms, and proper time ensures
thorough cleansing.
9. A nurse notices a client’s IV site is red, swollen, and painful. What is
the most appropriate action?
A. Slow the infusion rate
B. Apply a warm compress and continue infusion
C. Stop the infusion and remove the IV
D. Elevate the arm and monitor
Correct Answer: C
Rationale: Redness, swelling, and pain indicate phlebitis or infiltration. The
nurse should stop the infusion and remove the IV to prevent tissue damage
and infection. Continuing the infusion can worsen complications.
