Fundamentals of Nursing:
Comprehensive Exam Bank
Potter & Perry, 10th Edition – NCLEX-RN
Focused Practice 2026–2027
Section 1: Foundations of Nursing Practice
Question 1: The nurse is caring for a patient who is postoperative day 1 following abdominal surgery.
Which action is a priority to prevent respiratory complications?
A) Administer prescribed opioids regularly
B) Encourage incentive spirometry use every 2 hours
C) Limit ambulation to conserve energy
D) Maintain the patient in a supine position
Answer: B) Encourage incentive spirometry use every 2 hours
Rationale: Incentive spirometry promotes lung expansion and prevents atelectasis and pneumonia in
postoperative patients. Opioids may depress respiration; ambulation is encouraged; the supine position
restricts lung expansion.
Question 2: A patient has an order for a sterile dressing change. Which action by the nurse maintains
sterile field integrity?
A) The nurse reaches across the sterile field to obtain supplies
B) The nurse holds sterile objects at waist level
C) The nurse touches the sterile field with bare hands
D) The nurse turns their back to the sterile field
Answer: B) The nurse holds sterile objects at waist level
Rationale: The sterile field should be maintained within the nurse's line of sight and at waist level or
above. Reaching across, touching with bare hands, or turning away compromises sterility.
,Question 3: A patient with a history of falls is being admitted. Which intervention is most important for
fall prevention?
A) Place the bed in the highest position
B) Keep all four side rails up at all times
C) Place the call light within reach and orient the patient
D) Restrict the patient to bed rest only
Answer: C) Place the call light within reach and orient the patient
Rationale: Orienting the patient to the environment and ensuring the call light is within reach empowers
the patient to ask for assistance. Side rails should be used selectively (not all four up, as this may be
considered a restraint). High bed position increases fall risk; bed rest is not a safe long-term strategy.
Question 4: The nurse is assessing a patient's pain using the numerical rating scale (0–10). The patient
reports a 7. Which action should the nurse take first?
A) Administer a non-pharmacological intervention
B) Assess the patient's vital signs
C) Administer prescribed analgesic
D) Document the pain score
Answer: B) Assess the patient's vital signs
Rationale: Pain assessment should include vital signs (tachycardia, hypertension) as physiological
indicators, especially with moderate-to-severe pain (≥4/10). The nurse should assess, intervene, and re-
evaluate. Documentation is important but follows assessment.
Question 5: A patient has a nasogastric (NG) tube for gastric decompression. Which finding indicates
proper tube placement?
A) The patient is able to speak clearly
B) Aspirated gastric contents have a pH of 4
C) The tube is secured to the patient's gown
D) The patient has no discomfort
Answer: B) Aspirated gastric contents have a pH of 4
Rationale: Gastric aspirate pH should be ≤5.5 for proper NG tube placement confirmation. Speaking
clearly does not confirm placement; auscultation and X-ray are also used. Securing the tube is important,
but pH confirmation is more specific.
,Question 6: The nurse is preparing to administer an enteral feeding through a nasogastric tube. Before
initiating the feeding, the nurse should:
A) Flush the tube with 30 mL of water
B) Verify placement by auscultating the epigastric area
C) Administer the feeding at room temperature
D) Check residual volume
Answer: D) Check residual volume
Rationale: Checking gastric residual volume before enteral feeding assesses gastric emptying and risk of
aspiration. Flushing, auscultation, and temperature are important but residual check is a safety priority
before each feeding.
Question 7: A patient is receiving an intravenous infusion. The nurse notes the infusion site is swollen,
cool, and painful. The nurse should:
A) Continue the infusion and monitor
B) Slow the infusion rate
C) Discontinue the IV and restart in another site
D) Apply a warm compress
Answer: C) Discontinue the IV and restart in another site
Rationale: Swelling, coolness, and pain indicate infiltration—the IV fluid is leaking into surrounding
tissue. The IV should be discontinued and restarted. Continuing or slowing could worsen tissue damage;
warm compresses may be used after removal, but immediate discontinuation is priority.
Question 8: The nurse is performing hand hygiene. Which is the most effective method to reduce
transmission of microorganisms?
A) Using an alcohol-based hand rub for 15 seconds
B) Washing hands with soap and water for 15 seconds
C) Washing hands with soap and water for 40–60 seconds
D) Wiping hands with a dry paper towel
Answer: A) Using an alcohol-based hand rub for 15 seconds
Rationale: Alcohol-based hand rub is the preferred method for routine hand hygiene; it requires 15–30
seconds of rubbing until dry. Hand washing with soap and water is recommended for 40–60 seconds
when hands are visibly soiled or after using the restroom. Dry towel wiping is not effective.
, Question 9: The nurse is providing oral care to an unconscious patient. Which action is correct?
A) Use a toothbrush with firm bristles
B) Place the patient in a supine position
C) Use a soft toothbrush or foam swab and position the patient in side-lying position
D) Apply petroleum jelly to the tongue
Answer: C) Use a soft toothbrush or foam swab and position the patient in side-lying position
Rationale: Side-lying position prevents aspiration of secretions. A soft toothbrush or foam swab protects
fragile oral tissues. Firm bristles can cause trauma; supine position increases aspiration risk; petroleum
jelly should be applied to lips, not tongue.
Question 10: A patient is on contact precautions. Which personal protective equipment (PPE) should the
nurse wear when entering the room?
A) Gloves and gown
B) Gloves, gown, and mask
C) Gloves, gown, mask, and eye protection
D) Mask and gloves only
Answer: A) Gloves and gown
Rationale: Contact precautions require gloves and gown to prevent transmission via direct or indirect
contact. Masks and eye protection are added for droplet or airborne precautions, not contact alone.
Section 2: Vital Signs & Physical Assessment
Question 11: The nurse is assessing a patient's blood pressure using a manual sphygmomanometer. The
first Korotkoff sound corresponds to:
A) Diastolic pressure
B) Mean arterial pressure
C) Systolic pressure
D) Pulse pressure
Answer: C) Systolic pressure
Rationale: The first Korotkoff sound (phase I) corresponds to the systolic blood pressure—the pressure at
which blood flow resumes in the artery. The fifth sound (disappearance) corresponds to diastolic
pressure.
Comprehensive Exam Bank
Potter & Perry, 10th Edition – NCLEX-RN
Focused Practice 2026–2027
Section 1: Foundations of Nursing Practice
Question 1: The nurse is caring for a patient who is postoperative day 1 following abdominal surgery.
Which action is a priority to prevent respiratory complications?
A) Administer prescribed opioids regularly
B) Encourage incentive spirometry use every 2 hours
C) Limit ambulation to conserve energy
D) Maintain the patient in a supine position
Answer: B) Encourage incentive spirometry use every 2 hours
Rationale: Incentive spirometry promotes lung expansion and prevents atelectasis and pneumonia in
postoperative patients. Opioids may depress respiration; ambulation is encouraged; the supine position
restricts lung expansion.
Question 2: A patient has an order for a sterile dressing change. Which action by the nurse maintains
sterile field integrity?
A) The nurse reaches across the sterile field to obtain supplies
B) The nurse holds sterile objects at waist level
C) The nurse touches the sterile field with bare hands
D) The nurse turns their back to the sterile field
Answer: B) The nurse holds sterile objects at waist level
Rationale: The sterile field should be maintained within the nurse's line of sight and at waist level or
above. Reaching across, touching with bare hands, or turning away compromises sterility.
,Question 3: A patient with a history of falls is being admitted. Which intervention is most important for
fall prevention?
A) Place the bed in the highest position
B) Keep all four side rails up at all times
C) Place the call light within reach and orient the patient
D) Restrict the patient to bed rest only
Answer: C) Place the call light within reach and orient the patient
Rationale: Orienting the patient to the environment and ensuring the call light is within reach empowers
the patient to ask for assistance. Side rails should be used selectively (not all four up, as this may be
considered a restraint). High bed position increases fall risk; bed rest is not a safe long-term strategy.
Question 4: The nurse is assessing a patient's pain using the numerical rating scale (0–10). The patient
reports a 7. Which action should the nurse take first?
A) Administer a non-pharmacological intervention
B) Assess the patient's vital signs
C) Administer prescribed analgesic
D) Document the pain score
Answer: B) Assess the patient's vital signs
Rationale: Pain assessment should include vital signs (tachycardia, hypertension) as physiological
indicators, especially with moderate-to-severe pain (≥4/10). The nurse should assess, intervene, and re-
evaluate. Documentation is important but follows assessment.
Question 5: A patient has a nasogastric (NG) tube for gastric decompression. Which finding indicates
proper tube placement?
A) The patient is able to speak clearly
B) Aspirated gastric contents have a pH of 4
C) The tube is secured to the patient's gown
D) The patient has no discomfort
Answer: B) Aspirated gastric contents have a pH of 4
Rationale: Gastric aspirate pH should be ≤5.5 for proper NG tube placement confirmation. Speaking
clearly does not confirm placement; auscultation and X-ray are also used. Securing the tube is important,
but pH confirmation is more specific.
,Question 6: The nurse is preparing to administer an enteral feeding through a nasogastric tube. Before
initiating the feeding, the nurse should:
A) Flush the tube with 30 mL of water
B) Verify placement by auscultating the epigastric area
C) Administer the feeding at room temperature
D) Check residual volume
Answer: D) Check residual volume
Rationale: Checking gastric residual volume before enteral feeding assesses gastric emptying and risk of
aspiration. Flushing, auscultation, and temperature are important but residual check is a safety priority
before each feeding.
Question 7: A patient is receiving an intravenous infusion. The nurse notes the infusion site is swollen,
cool, and painful. The nurse should:
A) Continue the infusion and monitor
B) Slow the infusion rate
C) Discontinue the IV and restart in another site
D) Apply a warm compress
Answer: C) Discontinue the IV and restart in another site
Rationale: Swelling, coolness, and pain indicate infiltration—the IV fluid is leaking into surrounding
tissue. The IV should be discontinued and restarted. Continuing or slowing could worsen tissue damage;
warm compresses may be used after removal, but immediate discontinuation is priority.
Question 8: The nurse is performing hand hygiene. Which is the most effective method to reduce
transmission of microorganisms?
A) Using an alcohol-based hand rub for 15 seconds
B) Washing hands with soap and water for 15 seconds
C) Washing hands with soap and water for 40–60 seconds
D) Wiping hands with a dry paper towel
Answer: A) Using an alcohol-based hand rub for 15 seconds
Rationale: Alcohol-based hand rub is the preferred method for routine hand hygiene; it requires 15–30
seconds of rubbing until dry. Hand washing with soap and water is recommended for 40–60 seconds
when hands are visibly soiled or after using the restroom. Dry towel wiping is not effective.
, Question 9: The nurse is providing oral care to an unconscious patient. Which action is correct?
A) Use a toothbrush with firm bristles
B) Place the patient in a supine position
C) Use a soft toothbrush or foam swab and position the patient in side-lying position
D) Apply petroleum jelly to the tongue
Answer: C) Use a soft toothbrush or foam swab and position the patient in side-lying position
Rationale: Side-lying position prevents aspiration of secretions. A soft toothbrush or foam swab protects
fragile oral tissues. Firm bristles can cause trauma; supine position increases aspiration risk; petroleum
jelly should be applied to lips, not tongue.
Question 10: A patient is on contact precautions. Which personal protective equipment (PPE) should the
nurse wear when entering the room?
A) Gloves and gown
B) Gloves, gown, and mask
C) Gloves, gown, mask, and eye protection
D) Mask and gloves only
Answer: A) Gloves and gown
Rationale: Contact precautions require gloves and gown to prevent transmission via direct or indirect
contact. Masks and eye protection are added for droplet or airborne precautions, not contact alone.
Section 2: Vital Signs & Physical Assessment
Question 11: The nurse is assessing a patient's blood pressure using a manual sphygmomanometer. The
first Korotkoff sound corresponds to:
A) Diastolic pressure
B) Mean arterial pressure
C) Systolic pressure
D) Pulse pressure
Answer: C) Systolic pressure
Rationale: The first Korotkoff sound (phase I) corresponds to the systolic blood pressure—the pressure at
which blood flow resumes in the artery. The fifth sound (disappearance) corresponds to diastolic
pressure.
