NCLEX-RN PRACTICE EXAMINATION QUESTIONS WITH
CORRECT ANSWERS AND RATIONALES
1. A nurse is receiving a client who has just arrived on the medical-
surgical unit. Which action should the nurse take first?
A. Obtain the client's complete health history.
B. Assess the client's airway, breathing, and circulation.
C. Orient the client to the room.
D. Review the client's discharge instructions.
Correct answer: B. Assess the client's airway, breathing, and
circulation.
Rationale: The ABCs are assessed first because airway, breathing, and
circulation are essential to life. A complete history and orientation are
important but can follow the initial assessment.
2. A nurse is preparing to administer medication to a client. Which
identifiers should the nurse use? (Select all that apply.)
,A. Client's full name
B. Room number
C. Date of birth
D. Medical record number
E. Diagnosis
Correct answers: A, C, D.
Rationale: Two approved client identifiers, such as name, date of birth,
or medical record number, help prevent medication errors. Room
number and diagnosis are not reliable identifiers.
3. A client is at high risk for falls. Which intervention is most
appropriate?
A. Keep all four side rails raised.
B. Place the call light within reach.
C. Keep the bed in the highest position.
D. Encourage the client to walk independently.
,Correct answer: B. Place the call light within reach.
Rationale: A reachable call light promotes assistance-seeking and
reduces fall risk. Four side rails may be considered a restraint, and the
bed should be kept low.
4. A nurse is caring for a client with Clostridioides difficile infection.
Which personal protective equipment is required when entering the
room to provide direct care?
A. Surgical mask only
B. N95 respirator
C. Gown and gloves
D. Sterile gown and sterile gloves
Correct answer: C. Gown and gloves.
Rationale: Contact precautions for C. difficile include gloves and a
gown. Soap and water hand hygiene is preferred because alcohol-based
hand sanitizer does not reliably eliminate spores.
, 5. Which action by a nurse demonstrates correct use of standard
precautions?
A. Wearing gloves only for clients with known infections
B. Performing hand hygiene before and after client contact
C. Reusing disposable gloves between clients
D. Wearing an N95 respirator for every client
Correct answer: B. Performing hand hygiene before and after
client contact.
Rationale: Standard precautions apply to all clients and include hand
hygiene, appropriate PPE, and safe handling of equipment and sharps.
6. A nurse is caring for a client who has a newly inserted nasogastric
tube. Which finding requires immediate intervention?
A. The client reports mild nasal irritation.
B. The tube is secured to the nose.
C. The client develops coughing and respiratory distress during
insertion.
CORRECT ANSWERS AND RATIONALES
1. A nurse is receiving a client who has just arrived on the medical-
surgical unit. Which action should the nurse take first?
A. Obtain the client's complete health history.
B. Assess the client's airway, breathing, and circulation.
C. Orient the client to the room.
D. Review the client's discharge instructions.
Correct answer: B. Assess the client's airway, breathing, and
circulation.
Rationale: The ABCs are assessed first because airway, breathing, and
circulation are essential to life. A complete history and orientation are
important but can follow the initial assessment.
2. A nurse is preparing to administer medication to a client. Which
identifiers should the nurse use? (Select all that apply.)
,A. Client's full name
B. Room number
C. Date of birth
D. Medical record number
E. Diagnosis
Correct answers: A, C, D.
Rationale: Two approved client identifiers, such as name, date of birth,
or medical record number, help prevent medication errors. Room
number and diagnosis are not reliable identifiers.
3. A client is at high risk for falls. Which intervention is most
appropriate?
A. Keep all four side rails raised.
B. Place the call light within reach.
C. Keep the bed in the highest position.
D. Encourage the client to walk independently.
,Correct answer: B. Place the call light within reach.
Rationale: A reachable call light promotes assistance-seeking and
reduces fall risk. Four side rails may be considered a restraint, and the
bed should be kept low.
4. A nurse is caring for a client with Clostridioides difficile infection.
Which personal protective equipment is required when entering the
room to provide direct care?
A. Surgical mask only
B. N95 respirator
C. Gown and gloves
D. Sterile gown and sterile gloves
Correct answer: C. Gown and gloves.
Rationale: Contact precautions for C. difficile include gloves and a
gown. Soap and water hand hygiene is preferred because alcohol-based
hand sanitizer does not reliably eliminate spores.
, 5. Which action by a nurse demonstrates correct use of standard
precautions?
A. Wearing gloves only for clients with known infections
B. Performing hand hygiene before and after client contact
C. Reusing disposable gloves between clients
D. Wearing an N95 respirator for every client
Correct answer: B. Performing hand hygiene before and after
client contact.
Rationale: Standard precautions apply to all clients and include hand
hygiene, appropriate PPE, and safe handling of equipment and sharps.
6. A nurse is caring for a client who has a newly inserted nasogastric
tube. Which finding requires immediate intervention?
A. The client reports mild nasal irritation.
B. The tube is secured to the nose.
C. The client develops coughing and respiratory distress during
insertion.
