NCLEX-RN Ultimate Review &
Test Bank: NGN Practice
Questions with Rationales
Unit 1: Fundamentals of Nursing (Questions 1-25)
1. A nurse is preparing to administer a cleansing enema to a
client. Which of the following positions should the nurse place
the client in?
A. Supine
B. Left Sims' position
C. Prone
D. Right lateral position
Rationale: The left Sims' position allows the solution to flow by
gravity into the descending colon and sigmoid colon, promoting
effective cleansing.
2. A nurse is performing a sterile dressing change. Which of
the following actions demonstrates proper sterile technique?
A. Reaching over the sterile field to obtain supplies
B. Holding sterile items above the waist level
C. Placing sterile items on the bedside table
D. Using a sterile glove to touch non-sterile items
,Rationale: Sterile items must be held above waist level to
remain sterile. Reaching over a sterile field contaminates it.
Sterile items should be placed on a sterile drape, not a regular
bedside table.
3. A nurse is caring for a client who is on bed rest. Which of
the following interventions should the nurse implement to
prevent pressure ulcers?
A. Massage reddened areas vigorously
B. Reposition the client every 2 hours
C. Keep the head of the bed elevated at 90 degrees
D. Use hot water for bathing
Rationale: Repositioning every 2 hours relieves pressure on
bony prominences. Reddened areas should not be massaged.
The head of the bed should be elevated no more than 30
degrees to reduce shear and friction. Hot water dries the skin.
4. A nurse is assessing a client's level of consciousness. Which
of the following terms describes a client who is drowsy but
easily arousable?
A. Comatose
B. Stuporous
C. Lethargic
D. Alert
Rationale: Lethargy describes a state of drowsiness where the
client can be aroused easily but falls back to sleep quickly.
Stupor requires painful stimuli to arouse. Coma is unresponsive.
,5. A nurse is teaching a client about proper hand hygiene.
Which of the following statements by the client indicates
correct understanding?
A. "I should wash my hands for 5 seconds."
B. "I should wash my hands for at least 20 seconds."
C. "I should use hot water to kill all bacteria."
D. "I should skip hand washing if I use hand sanitizer."
Rationale: Hand washing should last at least 20 seconds with
soap and water. Warm water is recommended, not hot. Hand
sanitizer is not effective against C. difficile and should not
replace hand washing in all situations.
6. A nurse is documenting a client's intake and output. The
client drank 6 oz of tea, 8 oz of soup, and 4 oz of ice cream.
What is the total intake in mL?
A. 450 mL
B. 540 mL
C. 600 mL
D. 720 mL
Rationale: Convert ounces to mL (1 oz = 30 mL).
Tea: 6 oz × 30 = 180 mL.
Soup: 8 oz × 30 = 240 mL.
Ice cream: 4 oz × 30 = 120 mL.
Total: 180 + 240 + 120 = 540 mL.
7. A nurse is caring for a client who has a nasogastric (NG)
tube. Which of the following actions should the nurse take to
verify tube placement?
, A. Auscultate for air bubbles
B. Check the pH of gastric aspirate
C. Inject air into the tube
D. Measure the tube length
Rationale: Checking the pH of gastric aspirate is the most
reliable method at the bedside. Gastric pH is typically 0-4.
Auscultating for air bubbles is no longer recommended as it is
unreliable.
8. A nurse is providing oral care to an unconscious client.
Which of the following actions should the nurse take?
A. Turn the client's head to the side
B. Use a hard toothbrush
C. Administer small amounts of water
D. Place the client in a supine position
Rationale: Turning the head to the side allows secretions to
drain and prevents aspiration. An unconscious client should be
positioned in a side-lying position. Water should not be
administered orally to an unconscious client.
9. A nurse is teaching a client about the use of a cane. Which
of the following instructions should the nurse include?
A. "Hold the cane on your weaker side."
B. "Hold the cane on your stronger side."
C. "Move the cane and your weak leg together."
D. "The cane handle should be at hip level."
Test Bank: NGN Practice
Questions with Rationales
Unit 1: Fundamentals of Nursing (Questions 1-25)
1. A nurse is preparing to administer a cleansing enema to a
client. Which of the following positions should the nurse place
the client in?
A. Supine
B. Left Sims' position
C. Prone
D. Right lateral position
Rationale: The left Sims' position allows the solution to flow by
gravity into the descending colon and sigmoid colon, promoting
effective cleansing.
2. A nurse is performing a sterile dressing change. Which of
the following actions demonstrates proper sterile technique?
A. Reaching over the sterile field to obtain supplies
B. Holding sterile items above the waist level
C. Placing sterile items on the bedside table
D. Using a sterile glove to touch non-sterile items
,Rationale: Sterile items must be held above waist level to
remain sterile. Reaching over a sterile field contaminates it.
Sterile items should be placed on a sterile drape, not a regular
bedside table.
3. A nurse is caring for a client who is on bed rest. Which of
the following interventions should the nurse implement to
prevent pressure ulcers?
A. Massage reddened areas vigorously
B. Reposition the client every 2 hours
C. Keep the head of the bed elevated at 90 degrees
D. Use hot water for bathing
Rationale: Repositioning every 2 hours relieves pressure on
bony prominences. Reddened areas should not be massaged.
The head of the bed should be elevated no more than 30
degrees to reduce shear and friction. Hot water dries the skin.
4. A nurse is assessing a client's level of consciousness. Which
of the following terms describes a client who is drowsy but
easily arousable?
A. Comatose
B. Stuporous
C. Lethargic
D. Alert
Rationale: Lethargy describes a state of drowsiness where the
client can be aroused easily but falls back to sleep quickly.
Stupor requires painful stimuli to arouse. Coma is unresponsive.
,5. A nurse is teaching a client about proper hand hygiene.
Which of the following statements by the client indicates
correct understanding?
A. "I should wash my hands for 5 seconds."
B. "I should wash my hands for at least 20 seconds."
C. "I should use hot water to kill all bacteria."
D. "I should skip hand washing if I use hand sanitizer."
Rationale: Hand washing should last at least 20 seconds with
soap and water. Warm water is recommended, not hot. Hand
sanitizer is not effective against C. difficile and should not
replace hand washing in all situations.
6. A nurse is documenting a client's intake and output. The
client drank 6 oz of tea, 8 oz of soup, and 4 oz of ice cream.
What is the total intake in mL?
A. 450 mL
B. 540 mL
C. 600 mL
D. 720 mL
Rationale: Convert ounces to mL (1 oz = 30 mL).
Tea: 6 oz × 30 = 180 mL.
Soup: 8 oz × 30 = 240 mL.
Ice cream: 4 oz × 30 = 120 mL.
Total: 180 + 240 + 120 = 540 mL.
7. A nurse is caring for a client who has a nasogastric (NG)
tube. Which of the following actions should the nurse take to
verify tube placement?
, A. Auscultate for air bubbles
B. Check the pH of gastric aspirate
C. Inject air into the tube
D. Measure the tube length
Rationale: Checking the pH of gastric aspirate is the most
reliable method at the bedside. Gastric pH is typically 0-4.
Auscultating for air bubbles is no longer recommended as it is
unreliable.
8. A nurse is providing oral care to an unconscious client.
Which of the following actions should the nurse take?
A. Turn the client's head to the side
B. Use a hard toothbrush
C. Administer small amounts of water
D. Place the client in a supine position
Rationale: Turning the head to the side allows secretions to
drain and prevents aspiration. An unconscious client should be
positioned in a side-lying position. Water should not be
administered orally to an unconscious client.
9. A nurse is teaching a client about the use of a cane. Which
of the following instructions should the nurse include?
A. "Hold the cane on your weaker side."
B. "Hold the cane on your stronger side."
C. "Move the cane and your weak leg together."
D. "The cane handle should be at hip level."
