* *Fundamentals of Nursing Master Practice Test Bundle:
NCLEX-RN Readiness with Clinical Judgment**
---
**Question 1**
A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following
actions maintains aseptic technique?
A. Open the catheter kit and then put on sterile gloves
B. Place the sterile drape with the non-dominant hand covered by a sterile glove
C. Use the dominant hand to cleanse the perineum with antiseptic swabs
D. Once sterile gloves are on, adjust the sterile field with bare fingers if necessary
💫ANSWER✔️✔️: B. The non-dominant hand (which may be “clean” but not sterile) can be used to place
the sterile drape, as it will not touch the sterile field directly if covered by the drape’s edge. Standard
procedure: open outer wrapper, put on sterile gloves, then use sterile gloved hands to handle sterile
items. Option C is wrong (dominant hand should be sterile to cleanse). Option D is wrong (never adjust
with bare fingers).
💫RATIONALE✔️✔️: The correct aseptic technique: Open kit using the inner flap to create a sterile field.
Perform hand hygiene. Apply sterile gloves. With sterile dominant hand, cleanse the perineum. Hold the
catheter with sterile hand. The clean non-dominant hand separates labia.
---
**Question 2**
,A nurse is caring for a client who has a nasogastric (NG) tube set to low intermittent suction. Which
finding indicates the tube is properly placed?
A. The pH of aspirated fluid is 2
B. The client reports no nausea
C. The length of the tube from the nostril is 35 cm
D. The drainage is dark green
💫ANSWER✔️✔️: A. A gastric pH of 2 (strongly acidic) confirms the tube is in the stomach, not the lungs
or intestines. pH testing of aspirate is the most reliable bedside method to confirm gastric placement.
Gastric fluid pH is 1-5. Intestinal pH is >6. Respiratory pH is >6.
💫RATIONALE✔️✔️: The nurse should also verify placement with x-ray before initial use. Tube length (C) is
a baseline but can change. Drainage color (D) is variable.
---
**Question 3**
A nurse is providing postmortem care for a client who has died. The family is present and wishes to see
the body. Which action by the nurse demonstrates respect and cultural sensitivity?
A. Remove all tubes and equipment before the family enters
B. Ask the family if they have any specific rituals or customs they would like performed
C. Tell the family that the body must be cleaned and wrapped before they can enter
D. Leave the body as it is so the family can see the medical equipment used
💫ANSWER✔️✔️: B. Asking the family about their rituals respects their cultural and spiritual needs, which
vary widely (e.g., bathing by family, specific prayers, leaving tubes in place). Option A might violate a
custom (some families want to see the body before equipment is removed). Option C is insensitive.
Option D fails to provide a peaceful environment.
,💫RATIONALE✔️✔️: The nurse should offer the family time with the deceased, provide privacy, and
connect them with bereavement support. Postmortem care is done after the family has had time.
---
**Question 4**
A nurse is preparing to administer an intramuscular injection of hepatitis B vaccine to an adult. Which
site is preferred?
A. Ventrogluteal
B. Deltoid
C. Vastus lateralis
D. Dorsogluteal
💫ANSWER✔️✔️: B. The deltoid muscle is the preferred site for hepatitis B vaccine in adults due to good
absorption, safety, and established immunogenicity. The ventrogluteal (A) and vastus lateralis (C) are
acceptable but not preferred for this vaccine in adults. The dorsogluteal (D) is discouraged due to risk of
sciatic nerve injury and variable absorption.
💫RATIONALE✔️✔️: The deltoid is easily accessible, has fewer major nerves and vessels, and is
recommended by the CDC for routine adult vaccines. The nurse should use a 1-1.5 inch needle (22-25
gauge) for adults.
---
**Question 5**
A nurse is calculating the intake for a client from 0700 to 1500. The client drank 1 cup of coffee (240
mL), 6 oz of orange juice (180 mL), and 4 oz of water (120 mL). The client also received 500 mL of IV
fluids. What is the total intake in mL?
, A. 540 mL
B. 890 mL
C. 1040 mL
D. 940 mL
💫ANSWER✔️✔️: C. 1040 mL. Calculation: Coffee 240 mL + OJ 180 mL + Water 120 mL = 540 mL oral. +
500 mL IV = 1040 mL total. 1 cup = 8 oz = 240 mL. 6 oz = 180 mL. 4 oz = 120 mL.
💫RATIONALE✔️✔️: The nurse should also include other sources of intake: ice chips (record as half the
volume), tube feedings, IV flushes, blood products, and medications.
---
**Question 6**
A nurse is caring for a client who is receiving a continuous IV infusion of magnesium sulfate for
preeclampsia. The nurse notes absent deep tendon reflexes and a respiratory rate of 10 breaths per
minute. What is the priority nursing action?
A. Increase the IV infusion rate
B. Prepare for an emergency cesarean section
C. Discontinue the magnesium sulfate infusion
D. Administer calcium gluconate IV push
💫ANSWER✔️✔️: C. Discontinue the magnesium sulfate infusion immediately. These are signs of
magnesium toxicity. The first step is to stop the infusion. Then, call the provider, and prepare to
administer calcium gluconate (the antidote). Do not increase the infusion (A). C-section (B) is not the
first action.
NCLEX-RN Readiness with Clinical Judgment**
---
**Question 1**
A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following
actions maintains aseptic technique?
A. Open the catheter kit and then put on sterile gloves
B. Place the sterile drape with the non-dominant hand covered by a sterile glove
C. Use the dominant hand to cleanse the perineum with antiseptic swabs
D. Once sterile gloves are on, adjust the sterile field with bare fingers if necessary
💫ANSWER✔️✔️: B. The non-dominant hand (which may be “clean” but not sterile) can be used to place
the sterile drape, as it will not touch the sterile field directly if covered by the drape’s edge. Standard
procedure: open outer wrapper, put on sterile gloves, then use sterile gloved hands to handle sterile
items. Option C is wrong (dominant hand should be sterile to cleanse). Option D is wrong (never adjust
with bare fingers).
💫RATIONALE✔️✔️: The correct aseptic technique: Open kit using the inner flap to create a sterile field.
Perform hand hygiene. Apply sterile gloves. With sterile dominant hand, cleanse the perineum. Hold the
catheter with sterile hand. The clean non-dominant hand separates labia.
---
**Question 2**
,A nurse is caring for a client who has a nasogastric (NG) tube set to low intermittent suction. Which
finding indicates the tube is properly placed?
A. The pH of aspirated fluid is 2
B. The client reports no nausea
C. The length of the tube from the nostril is 35 cm
D. The drainage is dark green
💫ANSWER✔️✔️: A. A gastric pH of 2 (strongly acidic) confirms the tube is in the stomach, not the lungs
or intestines. pH testing of aspirate is the most reliable bedside method to confirm gastric placement.
Gastric fluid pH is 1-5. Intestinal pH is >6. Respiratory pH is >6.
💫RATIONALE✔️✔️: The nurse should also verify placement with x-ray before initial use. Tube length (C) is
a baseline but can change. Drainage color (D) is variable.
---
**Question 3**
A nurse is providing postmortem care for a client who has died. The family is present and wishes to see
the body. Which action by the nurse demonstrates respect and cultural sensitivity?
A. Remove all tubes and equipment before the family enters
B. Ask the family if they have any specific rituals or customs they would like performed
C. Tell the family that the body must be cleaned and wrapped before they can enter
D. Leave the body as it is so the family can see the medical equipment used
💫ANSWER✔️✔️: B. Asking the family about their rituals respects their cultural and spiritual needs, which
vary widely (e.g., bathing by family, specific prayers, leaving tubes in place). Option A might violate a
custom (some families want to see the body before equipment is removed). Option C is insensitive.
Option D fails to provide a peaceful environment.
,💫RATIONALE✔️✔️: The nurse should offer the family time with the deceased, provide privacy, and
connect them with bereavement support. Postmortem care is done after the family has had time.
---
**Question 4**
A nurse is preparing to administer an intramuscular injection of hepatitis B vaccine to an adult. Which
site is preferred?
A. Ventrogluteal
B. Deltoid
C. Vastus lateralis
D. Dorsogluteal
💫ANSWER✔️✔️: B. The deltoid muscle is the preferred site for hepatitis B vaccine in adults due to good
absorption, safety, and established immunogenicity. The ventrogluteal (A) and vastus lateralis (C) are
acceptable but not preferred for this vaccine in adults. The dorsogluteal (D) is discouraged due to risk of
sciatic nerve injury and variable absorption.
💫RATIONALE✔️✔️: The deltoid is easily accessible, has fewer major nerves and vessels, and is
recommended by the CDC for routine adult vaccines. The nurse should use a 1-1.5 inch needle (22-25
gauge) for adults.
---
**Question 5**
A nurse is calculating the intake for a client from 0700 to 1500. The client drank 1 cup of coffee (240
mL), 6 oz of orange juice (180 mL), and 4 oz of water (120 mL). The client also received 500 mL of IV
fluids. What is the total intake in mL?
, A. 540 mL
B. 890 mL
C. 1040 mL
D. 940 mL
💫ANSWER✔️✔️: C. 1040 mL. Calculation: Coffee 240 mL + OJ 180 mL + Water 120 mL = 540 mL oral. +
500 mL IV = 1040 mL total. 1 cup = 8 oz = 240 mL. 6 oz = 180 mL. 4 oz = 120 mL.
💫RATIONALE✔️✔️: The nurse should also include other sources of intake: ice chips (record as half the
volume), tube feedings, IV flushes, blood products, and medications.
---
**Question 6**
A nurse is caring for a client who is receiving a continuous IV infusion of magnesium sulfate for
preeclampsia. The nurse notes absent deep tendon reflexes and a respiratory rate of 10 breaths per
minute. What is the priority nursing action?
A. Increase the IV infusion rate
B. Prepare for an emergency cesarean section
C. Discontinue the magnesium sulfate infusion
D. Administer calcium gluconate IV push
💫ANSWER✔️✔️: C. Discontinue the magnesium sulfate infusion immediately. These are signs of
magnesium toxicity. The first step is to stop the infusion. Then, call the provider, and prepare to
administer calcium gluconate (the antidote). Do not increase the infusion (A). C-section (B) is not the
first action.
