NCLEX-RN Practice Questions: Nursing Fundamentals
Single-Best-Answer Questions
Q1 — Infection control (standard & airborne precautions)
Scenario / Recognize cues: A 68-year-old patient is admitted
with suspected pulmonary tuberculosis. He is coughing
frequently and has an elevated temperature. The room is a
negative-pressure airborne isolation room. The UAP asks which
personal protective equipment (PPE) is required before entering
the room to assist with hygiene.
Which PPE should the UAP don first before entering?
A. Surgical mask
B. N95 (or higher) respirator
C. Gown and gloves
D. Face shield
Correct Answer: B. N95 (or higher) respirator
Rationales (CJMM mapping):
• Recognize cues: Suspected TB (airborne), negative
pressure room, coughing — airborne spread risk.
• Analyze: Airborne pathogens require respiratory
protection that filters small particles — N95 or higher.
Surgical mask does not provide adequate filtration.
Gown/gloves protect against contact but not inhalation.
, Face shield protects mucous membranes from splashes but
is not respiratory filter.
• Decide: Use a respirator that provides airborne protection.
• Act (why B): N95 or higher respirator must be donned (fit-
checked) before room entry. Gown/gloves may be added
as indicated by contact precautions, but respirator is first
priority.
• Evaluate: Staff safety ensured; reduces inhalation risk.
Option rationales:
A. Surgical mask — Incorrect. Surgical masks block large
droplets, not small aerosolized particles; inadequate for
airborne TB.
B. N95 respirator — Correct. N95 or equivalent is
recommended for airborne infections (TB) to filter airborne
particles.
C. Gown and gloves — Incorrect as a first action. Important if
contact precautions are indicated, but do not protect against
inhalation of airborne organisms.
D. Face shield — Incorrect. Protects from splashes to face/eyes
but does not filter inhaled air; not a substitute for an N95.
Q2 — Patient safety (fall prevention & environment)
Recognize cues: A postoperative client (age 79) with PCA pump
is attempting to get out of bed unassisted late at night; vitals
are stable but the patient appears drowsy. You are the nurse on
,duty.
What is the most appropriate immediate action?
A. Apply a bed alarm and re-educate the patient about call light
use.
B. Assist the patient to sit at the bedside and evaluate level of
consciousness and pain control.
C. Administer an extra dose of opioid to relieve pain because
the patient is restless.
D. Place soft side rails up and leave the patient to rest.
Correct Answer: B. Assist the patient to sit at the bedside and
evaluate level of consciousness and pain control.
Rationales (CJMM mapping):
• Recognize cues: Age >65, postoperative, drowsy (sedation
risk), attempting unassisted ambulation — high fall risk.
PCA in use (opioid risk).
• Analyze: Immediate safety requires preventing a fall and
assessing cause of ambulation (pain, need to void,
disorientation, orthostatic hypotension). Drowsiness
suggests sedation — assess LOC and vitals.
• Decide: Safely assist to sitting position and perform quick
assessment.
• Act (why B): Helping patient sit prevents fall, allows
assessment (LOC, orthostatic changes, pain, PCA use).
Determine if medication reversal or monitoring is needed.
, • Evaluate: If sedation/instability identified, implement
restrictions and notify provider.
Option rationales:
A. Bed alarm & re-education — Incorrect as sole immediate
action. Alarm helps but does not prevent immediate fall while
patient is ambulating; re-education is secondary. Immediate
physical assistance is priority.
B. Assist to sit & evaluate — Correct. Prevents fall and identifies
cause (pain vs. oversedation) for further interventions.
C. Give extra opioid — Incorrect and potentially harmful.
Drowsiness suggests opioid effect; giving more could worsen
sedation and respiratory depression.
D. Soft side rails & leave — Incorrect. Side rails may restrain
unsteadily; leaving patient unattended is unsafe.
Q3 — Documentation (accuracy & legal aspects)
Recognize cues: You administered a medication 30 minutes late
due to an urgent code. The physician asks if the med was given.
Your chart currently shows the medication entry with scheduled
time but no administration time.
What is the correct documentation action?
A. Enter the scheduled time as the administration time to avoid
a medication error report.
B. Do not chart anything; discuss verbally with the physician
only.
Single-Best-Answer Questions
Q1 — Infection control (standard & airborne precautions)
Scenario / Recognize cues: A 68-year-old patient is admitted
with suspected pulmonary tuberculosis. He is coughing
frequently and has an elevated temperature. The room is a
negative-pressure airborne isolation room. The UAP asks which
personal protective equipment (PPE) is required before entering
the room to assist with hygiene.
Which PPE should the UAP don first before entering?
A. Surgical mask
B. N95 (or higher) respirator
C. Gown and gloves
D. Face shield
Correct Answer: B. N95 (or higher) respirator
Rationales (CJMM mapping):
• Recognize cues: Suspected TB (airborne), negative
pressure room, coughing — airborne spread risk.
• Analyze: Airborne pathogens require respiratory
protection that filters small particles — N95 or higher.
Surgical mask does not provide adequate filtration.
Gown/gloves protect against contact but not inhalation.
, Face shield protects mucous membranes from splashes but
is not respiratory filter.
• Decide: Use a respirator that provides airborne protection.
• Act (why B): N95 or higher respirator must be donned (fit-
checked) before room entry. Gown/gloves may be added
as indicated by contact precautions, but respirator is first
priority.
• Evaluate: Staff safety ensured; reduces inhalation risk.
Option rationales:
A. Surgical mask — Incorrect. Surgical masks block large
droplets, not small aerosolized particles; inadequate for
airborne TB.
B. N95 respirator — Correct. N95 or equivalent is
recommended for airborne infections (TB) to filter airborne
particles.
C. Gown and gloves — Incorrect as a first action. Important if
contact precautions are indicated, but do not protect against
inhalation of airborne organisms.
D. Face shield — Incorrect. Protects from splashes to face/eyes
but does not filter inhaled air; not a substitute for an N95.
Q2 — Patient safety (fall prevention & environment)
Recognize cues: A postoperative client (age 79) with PCA pump
is attempting to get out of bed unassisted late at night; vitals
are stable but the patient appears drowsy. You are the nurse on
,duty.
What is the most appropriate immediate action?
A. Apply a bed alarm and re-educate the patient about call light
use.
B. Assist the patient to sit at the bedside and evaluate level of
consciousness and pain control.
C. Administer an extra dose of opioid to relieve pain because
the patient is restless.
D. Place soft side rails up and leave the patient to rest.
Correct Answer: B. Assist the patient to sit at the bedside and
evaluate level of consciousness and pain control.
Rationales (CJMM mapping):
• Recognize cues: Age >65, postoperative, drowsy (sedation
risk), attempting unassisted ambulation — high fall risk.
PCA in use (opioid risk).
• Analyze: Immediate safety requires preventing a fall and
assessing cause of ambulation (pain, need to void,
disorientation, orthostatic hypotension). Drowsiness
suggests sedation — assess LOC and vitals.
• Decide: Safely assist to sitting position and perform quick
assessment.
• Act (why B): Helping patient sit prevents fall, allows
assessment (LOC, orthostatic changes, pain, PCA use).
Determine if medication reversal or monitoring is needed.
, • Evaluate: If sedation/instability identified, implement
restrictions and notify provider.
Option rationales:
A. Bed alarm & re-education — Incorrect as sole immediate
action. Alarm helps but does not prevent immediate fall while
patient is ambulating; re-education is secondary. Immediate
physical assistance is priority.
B. Assist to sit & evaluate — Correct. Prevents fall and identifies
cause (pain vs. oversedation) for further interventions.
C. Give extra opioid — Incorrect and potentially harmful.
Drowsiness suggests opioid effect; giving more could worsen
sedation and respiratory depression.
D. Soft side rails & leave — Incorrect. Side rails may restrain
unsteadily; leaving patient unattended is unsafe.
Q3 — Documentation (accuracy & legal aspects)
Recognize cues: You administered a medication 30 minutes late
due to an urgent code. The physician asks if the med was given.
Your chart currently shows the medication entry with scheduled
time but no administration time.
What is the correct documentation action?
A. Enter the scheduled time as the administration time to avoid
a medication error report.
B. Do not chart anything; discuss verbally with the physician
only.
