NUR 114 Exam 2: Fundamentals of Nursing NCLEX Rev… 2026/2027 • Verified • Assured Grade A+
✓ VERIFIED • 2026/2027 UPDATE • 100% ACCURATE
NUR 114 Exam 2: Fundamentals of Nursing NCLEX Review
2026/2027 UPDATE – Jefferson
ACTUAL EXAM QUESTIONS & VERIFIED ANSWERS
with Clear, Detailed Rationales
Document Type: Exam (Elaborations) / Study Guide
Academic Year:
Total Questions: 50 Multiple Choice
Includes: Correct Answers + Rationales
Grade: A+ Assured
ASSURED GRADE A+
Exam (Elaborations) • Detailed Rationales Page 1
,NUR 114 Exam 2: Fundamentals of Nursing NCLEX Rev… 2026/2027 • Verified • Assured Grade A+
Questions & Verified Answers
1. A nurse is caring for a client with a potassium level of 2.8 mEq/L. Which clinical
manifestation should the nurse prioritize for assessment?
A. Hyperactive bowel sounds
B. Increased muscle tone and tetany
C. Tachycardia and irregular heart rhythm
D. Elevated blood pressure
Answer: C
Rationale: Hypokalemia (potassium < 3.5 mEq/L) can lead to life-threatening cardiac dysrhythmias
and ECG changes such as U-waves. Options A and C are more characteristic of hyperkalemia or
hypocalcemia. This is important because the nurse must choose the action that keeps the client safest
while still meeting their basic needs. Always think about safety first when answering these questions.
In practice, this guides the nurse to set priorities and protect the client from harm. Safety, nutrition, and
clear communication are frequent priorities.
2. The nurse is analyzing the arterial blood gas (ABG) results of a client: pH 7.30, PaCO2 52
mmHg, and HCO3 26 mEq/L. Which acid-base imbalance is the client experiencing?
A. Respiratory acidosis
B. Metabolic alkalosis
C. Metabolic acidosis
D. Respiratory alkalosis
Answer: A
Rationale: A pH below 7.35 indicates acidosis. A PaCO2 above 45 mmHg indicates a respiratory
cause. Since the pH is low and PaCO2 is high, it is respiratory acidosis. This is important because the
nurse must choose the action that keeps the client safest while still meeting their basic needs. Always
think about safety first when answering these questions. In practice, this guides the nurse to set
priorities and protect the client from harm. Safety, nutrition, and clear communication are frequent
priorities.
Exam (Elaborations) • Detailed Rationales Page 2
, NUR 114 Exam 2: Fundamentals of Nursing NCLEX Rev… 2026/2027 • Verified • Assured Grade A+
3. A client has a deep wound with full-thickness skin loss involving damage to
subcutaneous tissue but not extending to the fascia. How should the nurse document this
pressure injury?
A. Stage 1
B. Stage 3
C. Stage 2
D. Stage 4
Answer: B
Rationale: Stage 3 pressure injuries involve full-thickness skin loss with visible adipose (fat) and
granulation tissue, but muscles, tendons, or bones are not exposed. This is important because the
nurse must choose the action that keeps the client safest while still meeting their basic needs. Always
think about safety first when answering these questions. This knowledge supports safe care and helps
the nurse teach the client and family clearly and simply. Clear teaching improves cooperation and
reduces anxiety.
4. Which action is most critical for the nurse to perform to prevent a catheter-associated
urinary tract infection (CAUTI)?
A. Maintaining a closed drainage system
B. Cleaning the perineal area with antiseptic wipes every 4 hours
C. Changing the catheter every 7 days
D. Ensuring the drainage bag is placed on the client’s bed during transport
Answer: A
Rationale: Maintaining a closed drainage system is the primary evidence-based intervention to
prevent CAUTI. The bag should always be below the level of the bladder. This knowledge supports
safe care and helps the nurse teach the client and family clearly and simply. Clear teaching improves
cooperation and reduces anxiety. Knowing the reason behind the correct answer makes it easier to
rule out the wrong options quickly. Look for the choice that protects the client and matches the priority
need.
Exam (Elaborations) • Detailed Rationales Page 3
✓ VERIFIED • 2026/2027 UPDATE • 100% ACCURATE
NUR 114 Exam 2: Fundamentals of Nursing NCLEX Review
2026/2027 UPDATE – Jefferson
ACTUAL EXAM QUESTIONS & VERIFIED ANSWERS
with Clear, Detailed Rationales
Document Type: Exam (Elaborations) / Study Guide
Academic Year:
Total Questions: 50 Multiple Choice
Includes: Correct Answers + Rationales
Grade: A+ Assured
ASSURED GRADE A+
Exam (Elaborations) • Detailed Rationales Page 1
,NUR 114 Exam 2: Fundamentals of Nursing NCLEX Rev… 2026/2027 • Verified • Assured Grade A+
Questions & Verified Answers
1. A nurse is caring for a client with a potassium level of 2.8 mEq/L. Which clinical
manifestation should the nurse prioritize for assessment?
A. Hyperactive bowel sounds
B. Increased muscle tone and tetany
C. Tachycardia and irregular heart rhythm
D. Elevated blood pressure
Answer: C
Rationale: Hypokalemia (potassium < 3.5 mEq/L) can lead to life-threatening cardiac dysrhythmias
and ECG changes such as U-waves. Options A and C are more characteristic of hyperkalemia or
hypocalcemia. This is important because the nurse must choose the action that keeps the client safest
while still meeting their basic needs. Always think about safety first when answering these questions.
In practice, this guides the nurse to set priorities and protect the client from harm. Safety, nutrition, and
clear communication are frequent priorities.
2. The nurse is analyzing the arterial blood gas (ABG) results of a client: pH 7.30, PaCO2 52
mmHg, and HCO3 26 mEq/L. Which acid-base imbalance is the client experiencing?
A. Respiratory acidosis
B. Metabolic alkalosis
C. Metabolic acidosis
D. Respiratory alkalosis
Answer: A
Rationale: A pH below 7.35 indicates acidosis. A PaCO2 above 45 mmHg indicates a respiratory
cause. Since the pH is low and PaCO2 is high, it is respiratory acidosis. This is important because the
nurse must choose the action that keeps the client safest while still meeting their basic needs. Always
think about safety first when answering these questions. In practice, this guides the nurse to set
priorities and protect the client from harm. Safety, nutrition, and clear communication are frequent
priorities.
Exam (Elaborations) • Detailed Rationales Page 2
, NUR 114 Exam 2: Fundamentals of Nursing NCLEX Rev… 2026/2027 • Verified • Assured Grade A+
3. A client has a deep wound with full-thickness skin loss involving damage to
subcutaneous tissue but not extending to the fascia. How should the nurse document this
pressure injury?
A. Stage 1
B. Stage 3
C. Stage 2
D. Stage 4
Answer: B
Rationale: Stage 3 pressure injuries involve full-thickness skin loss with visible adipose (fat) and
granulation tissue, but muscles, tendons, or bones are not exposed. This is important because the
nurse must choose the action that keeps the client safest while still meeting their basic needs. Always
think about safety first when answering these questions. This knowledge supports safe care and helps
the nurse teach the client and family clearly and simply. Clear teaching improves cooperation and
reduces anxiety.
4. Which action is most critical for the nurse to perform to prevent a catheter-associated
urinary tract infection (CAUTI)?
A. Maintaining a closed drainage system
B. Cleaning the perineal area with antiseptic wipes every 4 hours
C. Changing the catheter every 7 days
D. Ensuring the drainage bag is placed on the client’s bed during transport
Answer: A
Rationale: Maintaining a closed drainage system is the primary evidence-based intervention to
prevent CAUTI. The bag should always be below the level of the bladder. This knowledge supports
safe care and helps the nurse teach the client and family clearly and simply. Clear teaching improves
cooperation and reduces anxiety. Knowing the reason behind the correct answer makes it easier to
rule out the wrong options quickly. Look for the choice that protects the client and matches the priority
need.
Exam (Elaborations) • Detailed Rationales Page 3
