NCLEX RN FUNDAMENTALS NEWEST 2024 ACTUAL EXAM COMPLETE 100 QUESTIONS AND CORRECT
DETAILED ANSWERS
The nurse encourages a patient with a history of heart failure to reduce energy expenditure by
alternating activity and rest. Which nursing process phase is this?
a. Diagnosis
b. Planning
c. Implementation
d. Evaluation - (answer) C. Implementation
Teaching a patient about alternating activity and rest is a component of patient education, which falls
into the implementation phase. This is an example of putting an individualized plan into action. Other
components of implementation include assisting with hygienic care, promoting physical comfort,
supporting respiratory and elimination functions, facilitating ingestion of food/fluids, managing the
patient's surroundings, promoting a therapeutic relationship, and carrying out other therapeutic nursing
activities.
The nurse on the medical-surgical unit is interested in implementing evidence-based practice. The nurse
knows when evidence-based practice is utilized:
a. National health agencies create clinical practice guidelines that must be used.
b. Findings from randomized trials are used to plan care.
c. Clinical decision-making and nursing judgment are used to find which evidence works for each specific
situation in clinical practice.
d. Nursing interventions are statistically analyzed by a nurse in relation to patient outcomes to discover
evidence for appropriate patient interventions. - (answer) c. Clinical decision-making and nursing
judgment are used to find which evidence works for each specific situation in clinical practice.
Evidence-based practice is based on evidence from nurses working with actual patients to find the best
interventions for the best outcomes. It is through this evidence that nurses develop and improve their
practice to achieve even greater patient outcomes. It is imperative that nurses continue to learn and
improve their skills and use updated techniques as technology changes and patients have increasing
acuity.
New nurses in orientation are learning about completion of incident reports. Which of the following
incidents would require an incident report be filed?
a. Medication given 30 minutes before scheduled time
,NCLEX RN FUNDAMENTALS NEWEST 2024 ACTUAL EXAM COMPLETE 100 QUESTIONS AND CORRECT
DETAILED ANSWERS
b. Patient belongings lost when transferred to their hospital room
c. Frayed electrical cord on an IV pump
d. Medication order - (answer) b. Patient belongings lost when transferred to their hospital room
Any time a patient's belongings are lost an incident report must be filed. This can help identify people
and departments involved, ways to prevent the occurrence in the future, and even help in locating
belongings.
A nurse enters a patient's room to deliver medications that are due and discovers the patient is in the
bathroom. Which of the following actions by the nurse is appropriate?
a. Place the medication on the bedside table
b. Place the medication on the bedside table and tell the patient not to forget to take them
c. Ask the patient to call when out of the bathroom and give the medications at that time
d. Ask the patient to call when out of the bathroom and leave the medications on the bedside table -
(answer) c. Ask the patient to call when out of the bathroom and give the medications at that time
The nurse should return when the patient is available to take the medications so the nurse can verify the
medications have been taken. The nurse should never leave medications on the bedside table.
A, B, C are incorrect because medications should never be left in the patient room.
The nurse is preparing to perform a focused assessment of the patient's abdomen. Which of the
following choices is the correct order in which the focused assessment is performed?
a. Palpation, Auscultation, Inspection, Percussion
b. Inspection, Palpation, Percussion, Auscultation
c. Percussion, Palpation, Inspection, Auscultation
d. Inspection, Auscultation, Percussion, Palpation - (answer) d. Inspection, Auscultation, Percussion,
Palpation
When performing an abdominal assessment, inspection and auscultation should be performed prior to
percussion and palpation because the last two techniques will alter bowel sounds. Inspection is looking
at the appearance of the abdomen while the patient is lying supine, with their arms by their side, and
,NCLEX RN FUNDAMENTALS NEWEST 2024 ACTUAL EXAM COMPLETE 100 QUESTIONS AND CORRECT
DETAILED ANSWERS
head resting on a pillow. (If the neck is flexed, abdominal muscles may become flexed, and this can alter
the appearance during assessment.).
Auscultation is performed over all four quadrants. Consider, are bowel sounds present? What are the
quality and quantity of the bowel sounds? Note any regional differences among the four quadrants.
Percussion is performed by the fingers to test for dullness (solid mass) and tympany (air or gas).
Palpation is performed to discover any pain or tenderness. When palpating, apply slow, steady pressure
and avoid sharp movements that may cause discomfort.
A patient is in the clinic with complaints of "not feeling well." The nurse knows the patient's primary
defense against infection is:
a. Fever
b. Intact skin
c. Inflammation
d. Lethargy - (answer) b. Intact skin
The primary defense from infection is intact skin. Breaks in the skin allow a route for infection to invade.
A is incorrect because fever is a secondary defense against infection. Fever is significant when above
100.4℉ or 38℃.
C is incorrect because inflammation is a secondary defense against infection. Inflammation produces
redness, pain, swelling, and warmth as a result of infection, irritation, or injury. The body heals during
the inflammatory process as leukocytes and proteins migrate to the area in order to fight infection and
repair damage.
D is incorrect because lethargy is not a defense against infection. Lethargy can be a symptom of
infection.
The nurse on the medical unit is caring for a patient who does not speak English, and the nurse does not
understand the patient's language. Which of the following is most appropriate for the nurse to do when
speaking with the patient?
a. Have the patient's wife translate
b. Speak using medical terminology to avoid misunderstanding
c. Keep in mind translation is more important than nonverbal communication
d. Have a certified medical interpreter translate - (answer) d. Have a certified medical interpreter
translate
, NCLEX RN FUNDAMENTALS NEWEST 2024 ACTUAL EXAM COMPLETE 100 QUESTIONS AND CORRECT
DETAILED ANSWERS
Medical interpreters are certified in translation for scenarios like this. Rigorous training and testing is
performed before becoming a medical interpreter, so this is the best way to interpret for a patient and
prevent mistakes and misunderstandings.
The nurse is completing the preoperative checklist for a patient scheduled for surgery. In reviewing the
chart, the nurse finds the consent has not been signed by the patient. When the patient starts asking
questions regarding the surgery, what is the next action the nurse should take?
a. Have the patient sign the consent
b. Tell the patient all questions will be answered by the surgeon before the anesthesiologist administers
anesthetic
c. Contact the surgeon to inform them the patient has questions regarding the procedure
d. Answer all the patient's questions - (answer) c. Contact the surgeon to inform them the patient has
questions regarding the procedure
Before any invasive procedure, the surgeon must inform the patient of what the procedure entails, the
purpose for the procedure, and the potential risks associated with that procedure before the consent is
signed by the patient. (Hence the term "informed consent.") If the consent has not been signed and the
patient has questions, the healthcare provider has not reviewed the procedure and risks involved and
needs to do so before the procedure.
The nurse is caring for a patient who had an endoscopic total hysterectomy and is now experiencing
urinary retention. The nurse is preparing to contact the healthcare provider using SBAR (situation
background assessment recommendation). Which of the following questions is a part of SBAR
communication?
a. "Could you tell me what I need to do?"
b. "What do you need to know about the patient?"
c. "I believe the patient needs a urinary catheter."
d. "Why do you think the patient is unable to urinate?" - (answer) c. "I believe the patient needs a
urinary catheter."
Making a recommendation to the healthcare provider is part of SBAR.
DETAILED ANSWERS
The nurse encourages a patient with a history of heart failure to reduce energy expenditure by
alternating activity and rest. Which nursing process phase is this?
a. Diagnosis
b. Planning
c. Implementation
d. Evaluation - (answer) C. Implementation
Teaching a patient about alternating activity and rest is a component of patient education, which falls
into the implementation phase. This is an example of putting an individualized plan into action. Other
components of implementation include assisting with hygienic care, promoting physical comfort,
supporting respiratory and elimination functions, facilitating ingestion of food/fluids, managing the
patient's surroundings, promoting a therapeutic relationship, and carrying out other therapeutic nursing
activities.
The nurse on the medical-surgical unit is interested in implementing evidence-based practice. The nurse
knows when evidence-based practice is utilized:
a. National health agencies create clinical practice guidelines that must be used.
b. Findings from randomized trials are used to plan care.
c. Clinical decision-making and nursing judgment are used to find which evidence works for each specific
situation in clinical practice.
d. Nursing interventions are statistically analyzed by a nurse in relation to patient outcomes to discover
evidence for appropriate patient interventions. - (answer) c. Clinical decision-making and nursing
judgment are used to find which evidence works for each specific situation in clinical practice.
Evidence-based practice is based on evidence from nurses working with actual patients to find the best
interventions for the best outcomes. It is through this evidence that nurses develop and improve their
practice to achieve even greater patient outcomes. It is imperative that nurses continue to learn and
improve their skills and use updated techniques as technology changes and patients have increasing
acuity.
New nurses in orientation are learning about completion of incident reports. Which of the following
incidents would require an incident report be filed?
a. Medication given 30 minutes before scheduled time
,NCLEX RN FUNDAMENTALS NEWEST 2024 ACTUAL EXAM COMPLETE 100 QUESTIONS AND CORRECT
DETAILED ANSWERS
b. Patient belongings lost when transferred to their hospital room
c. Frayed electrical cord on an IV pump
d. Medication order - (answer) b. Patient belongings lost when transferred to their hospital room
Any time a patient's belongings are lost an incident report must be filed. This can help identify people
and departments involved, ways to prevent the occurrence in the future, and even help in locating
belongings.
A nurse enters a patient's room to deliver medications that are due and discovers the patient is in the
bathroom. Which of the following actions by the nurse is appropriate?
a. Place the medication on the bedside table
b. Place the medication on the bedside table and tell the patient not to forget to take them
c. Ask the patient to call when out of the bathroom and give the medications at that time
d. Ask the patient to call when out of the bathroom and leave the medications on the bedside table -
(answer) c. Ask the patient to call when out of the bathroom and give the medications at that time
The nurse should return when the patient is available to take the medications so the nurse can verify the
medications have been taken. The nurse should never leave medications on the bedside table.
A, B, C are incorrect because medications should never be left in the patient room.
The nurse is preparing to perform a focused assessment of the patient's abdomen. Which of the
following choices is the correct order in which the focused assessment is performed?
a. Palpation, Auscultation, Inspection, Percussion
b. Inspection, Palpation, Percussion, Auscultation
c. Percussion, Palpation, Inspection, Auscultation
d. Inspection, Auscultation, Percussion, Palpation - (answer) d. Inspection, Auscultation, Percussion,
Palpation
When performing an abdominal assessment, inspection and auscultation should be performed prior to
percussion and palpation because the last two techniques will alter bowel sounds. Inspection is looking
at the appearance of the abdomen while the patient is lying supine, with their arms by their side, and
,NCLEX RN FUNDAMENTALS NEWEST 2024 ACTUAL EXAM COMPLETE 100 QUESTIONS AND CORRECT
DETAILED ANSWERS
head resting on a pillow. (If the neck is flexed, abdominal muscles may become flexed, and this can alter
the appearance during assessment.).
Auscultation is performed over all four quadrants. Consider, are bowel sounds present? What are the
quality and quantity of the bowel sounds? Note any regional differences among the four quadrants.
Percussion is performed by the fingers to test for dullness (solid mass) and tympany (air or gas).
Palpation is performed to discover any pain or tenderness. When palpating, apply slow, steady pressure
and avoid sharp movements that may cause discomfort.
A patient is in the clinic with complaints of "not feeling well." The nurse knows the patient's primary
defense against infection is:
a. Fever
b. Intact skin
c. Inflammation
d. Lethargy - (answer) b. Intact skin
The primary defense from infection is intact skin. Breaks in the skin allow a route for infection to invade.
A is incorrect because fever is a secondary defense against infection. Fever is significant when above
100.4℉ or 38℃.
C is incorrect because inflammation is a secondary defense against infection. Inflammation produces
redness, pain, swelling, and warmth as a result of infection, irritation, or injury. The body heals during
the inflammatory process as leukocytes and proteins migrate to the area in order to fight infection and
repair damage.
D is incorrect because lethargy is not a defense against infection. Lethargy can be a symptom of
infection.
The nurse on the medical unit is caring for a patient who does not speak English, and the nurse does not
understand the patient's language. Which of the following is most appropriate for the nurse to do when
speaking with the patient?
a. Have the patient's wife translate
b. Speak using medical terminology to avoid misunderstanding
c. Keep in mind translation is more important than nonverbal communication
d. Have a certified medical interpreter translate - (answer) d. Have a certified medical interpreter
translate
, NCLEX RN FUNDAMENTALS NEWEST 2024 ACTUAL EXAM COMPLETE 100 QUESTIONS AND CORRECT
DETAILED ANSWERS
Medical interpreters are certified in translation for scenarios like this. Rigorous training and testing is
performed before becoming a medical interpreter, so this is the best way to interpret for a patient and
prevent mistakes and misunderstandings.
The nurse is completing the preoperative checklist for a patient scheduled for surgery. In reviewing the
chart, the nurse finds the consent has not been signed by the patient. When the patient starts asking
questions regarding the surgery, what is the next action the nurse should take?
a. Have the patient sign the consent
b. Tell the patient all questions will be answered by the surgeon before the anesthesiologist administers
anesthetic
c. Contact the surgeon to inform them the patient has questions regarding the procedure
d. Answer all the patient's questions - (answer) c. Contact the surgeon to inform them the patient has
questions regarding the procedure
Before any invasive procedure, the surgeon must inform the patient of what the procedure entails, the
purpose for the procedure, and the potential risks associated with that procedure before the consent is
signed by the patient. (Hence the term "informed consent.") If the consent has not been signed and the
patient has questions, the healthcare provider has not reviewed the procedure and risks involved and
needs to do so before the procedure.
The nurse is caring for a patient who had an endoscopic total hysterectomy and is now experiencing
urinary retention. The nurse is preparing to contact the healthcare provider using SBAR (situation
background assessment recommendation). Which of the following questions is a part of SBAR
communication?
a. "Could you tell me what I need to do?"
b. "What do you need to know about the patient?"
c. "I believe the patient needs a urinary catheter."
d. "Why do you think the patient is unable to urinate?" - (answer) c. "I believe the patient needs a
urinary catheter."
Making a recommendation to the healthcare provider is part of SBAR.
