Comprehensive NCLEX-RN
Examination Review: Practice
Questions with Rationales
Safe and Effective Care Environment
Question: A nurse is preparing to administer a blood transfusion to a client.
Which action is the priority to ensure client safety?
Answer: Verify the client's identity using two unique identifiers and match
the blood product to the order and the client's blood type.
Rationale: The priority in any blood transfusion is to prevent a hemolytic
reaction caused by administering the wrong blood product. Verifying the
client's identity and blood product compatibility is the most critical safety
check. Other actions, like starting an IV with a large-gauge catheter and
assessing vitals, are important but secondary to correct identification.
Question: A nurse enters a client's room and finds the client on the floor.
Which is the nurse's first action?
Answer: Assess the client for injury.
Rationale: The immediate priority is to assess the client's airway, breathing,
and circulation (ABCs) and check for any injuries sustained from the fall.
Activating the emergency response system or calling for help should be
done only after a primary survey is complete and immediate threats to life
are addressed. Moving the client without a proper assessment can cause
further harm, especially if a spinal injury is suspected.
,Question: A charge nurse is assigning a client with a diagnosis of
methicillin-resistant Staphylococcus aureus (MRSA) infection to a new
graduate nurse. What instruction should the charge nurse prioritize?
Answer: "Ensure strict adherence to contact precautions, including wearing
a gown and gloves for all interactions in the client's room."
Rationale: MRSA is transmitted primarily by direct contact. Standard
precautions are not enough; contact precautions are required to prevent
the spread of the organism. Hand hygiene is always crucial, but contact
precautions mandate the use of PPE to protect both the nurse and other
clients. The assignment itself is appropriate if the graduate has been
oriented.
Question: A nurse is educating a client about home safety. Which
statement by the client indicates a need for further teaching?
Answer: "I will keep all my medications in a single, easy-to-reach container
to manage them more simply."
Rationale: Keeping all medications in one container can lead to confusion
and accidental overdose, especially if medications look similar. The client
should keep medications in their original, labeled containers. Other
statements about wearing non-slip footwear, using nightlights, and
removing clutter are all appropriate and indicate good understanding.
Question: A nurse is preparing to perform a sterile dressing change. Which
action is a break in sterile technique?
Answer: The nurse places a sterile item on the sterile field, then reaches
over the sterile field to open a new pack of gauze.
Rationale: Reaching over a sterile field contaminates it. The nurse should
avoid reaching over the sterile field. The 1-inch border of the sterile field is
indeed considered contaminated. Placing a sterile item outside the field is
safe, and pouring sterile solution into a sterile container is also appropriate.
, Question: A nurse manager is discussing incident reports with the staff.
Which statement by the staff nurse indicates an understanding of the
purpose of an incident report?
Answer: "The primary purpose of an incident report is to identify risks and
improve client safety through quality improvement."
Rationale: The purpose of an incident report is to document adverse
events, near misses, and unsafe conditions to identify patterns and
implement system changes to prevent future occurrences. They should be
factual and confidential, not placed in the client's chart, and should not
assign blame.
Question: A nurse is caring for a client post-surgery who has an indwelling
urinary catheter. Which action is most appropriate to prevent catheter-
associated urinary tract infection (CAUTI)?
Answer: Ensure the catheter bag is positioned below the level of the
client's bladder and keep the drainage tubing free of kinks.
Rationale: Maintaining a closed, gravity-dependent drainage system
prevents urine from backflowing into the bladder, reducing the risk of
infection. Routine, scheduled catheter changes are not recommended
unless there is a specific indication. Restricting fluids can increase the risk of
infection and is contraindicated.
Question: A nurse is discharging a client who has a history of falls. Which
recommendation is most important to include in the discharge teaching?
Answer: Have grab bars installed in the bathroom and handrails on all
stairways.
Rationale: The home environment is a major risk factor for falls. Physical
modifications, such as grab bars and handrails, are evidence-based
interventions that provide support and reduce fall risk. Other
recommendations, like wearing non-skid socks and using nightlights, are
Examination Review: Practice
Questions with Rationales
Safe and Effective Care Environment
Question: A nurse is preparing to administer a blood transfusion to a client.
Which action is the priority to ensure client safety?
Answer: Verify the client's identity using two unique identifiers and match
the blood product to the order and the client's blood type.
Rationale: The priority in any blood transfusion is to prevent a hemolytic
reaction caused by administering the wrong blood product. Verifying the
client's identity and blood product compatibility is the most critical safety
check. Other actions, like starting an IV with a large-gauge catheter and
assessing vitals, are important but secondary to correct identification.
Question: A nurse enters a client's room and finds the client on the floor.
Which is the nurse's first action?
Answer: Assess the client for injury.
Rationale: The immediate priority is to assess the client's airway, breathing,
and circulation (ABCs) and check for any injuries sustained from the fall.
Activating the emergency response system or calling for help should be
done only after a primary survey is complete and immediate threats to life
are addressed. Moving the client without a proper assessment can cause
further harm, especially if a spinal injury is suspected.
,Question: A charge nurse is assigning a client with a diagnosis of
methicillin-resistant Staphylococcus aureus (MRSA) infection to a new
graduate nurse. What instruction should the charge nurse prioritize?
Answer: "Ensure strict adherence to contact precautions, including wearing
a gown and gloves for all interactions in the client's room."
Rationale: MRSA is transmitted primarily by direct contact. Standard
precautions are not enough; contact precautions are required to prevent
the spread of the organism. Hand hygiene is always crucial, but contact
precautions mandate the use of PPE to protect both the nurse and other
clients. The assignment itself is appropriate if the graduate has been
oriented.
Question: A nurse is educating a client about home safety. Which
statement by the client indicates a need for further teaching?
Answer: "I will keep all my medications in a single, easy-to-reach container
to manage them more simply."
Rationale: Keeping all medications in one container can lead to confusion
and accidental overdose, especially if medications look similar. The client
should keep medications in their original, labeled containers. Other
statements about wearing non-slip footwear, using nightlights, and
removing clutter are all appropriate and indicate good understanding.
Question: A nurse is preparing to perform a sterile dressing change. Which
action is a break in sterile technique?
Answer: The nurse places a sterile item on the sterile field, then reaches
over the sterile field to open a new pack of gauze.
Rationale: Reaching over a sterile field contaminates it. The nurse should
avoid reaching over the sterile field. The 1-inch border of the sterile field is
indeed considered contaminated. Placing a sterile item outside the field is
safe, and pouring sterile solution into a sterile container is also appropriate.
, Question: A nurse manager is discussing incident reports with the staff.
Which statement by the staff nurse indicates an understanding of the
purpose of an incident report?
Answer: "The primary purpose of an incident report is to identify risks and
improve client safety through quality improvement."
Rationale: The purpose of an incident report is to document adverse
events, near misses, and unsafe conditions to identify patterns and
implement system changes to prevent future occurrences. They should be
factual and confidential, not placed in the client's chart, and should not
assign blame.
Question: A nurse is caring for a client post-surgery who has an indwelling
urinary catheter. Which action is most appropriate to prevent catheter-
associated urinary tract infection (CAUTI)?
Answer: Ensure the catheter bag is positioned below the level of the
client's bladder and keep the drainage tubing free of kinks.
Rationale: Maintaining a closed, gravity-dependent drainage system
prevents urine from backflowing into the bladder, reducing the risk of
infection. Routine, scheduled catheter changes are not recommended
unless there is a specific indication. Restricting fluids can increase the risk of
infection and is contraindicated.
Question: A nurse is discharging a client who has a history of falls. Which
recommendation is most important to include in the discharge teaching?
Answer: Have grab bars installed in the bathroom and handrails on all
stairways.
Rationale: The home environment is a major risk factor for falls. Physical
modifications, such as grab bars and handrails, are evidence-based
interventions that provide support and reduce fall risk. Other
recommendations, like wearing non-skid socks and using nightlights, are
