NCLEX Fundamentals Practice
— Batch 1 (Basic Care &
Comfort)
1. A nurse is providing mouth care to an
unconscious patient. What action is most
important?
A. Use lemon-glycerin swabs to clean the mouth.
B. Place the patient in a side-lying position.
C. Rinse with large amounts of water.
D. Use firm pressure with the toothbrush.
Answer: B
Rationale: The side-lying position prevents
aspiration during oral care. Lemon-glycerin swabs
cause mucosal dryness, and large amounts of
water increase aspiration risk.
2. The nurse is teaching a patient about proper use
of an incentive spirometer. Which statement
indicates correct understanding?
A. “I’ll blow into it as hard as I can.”
B. “I’ll inhale slowly and deeply.”
C. “I’ll exhale quickly into the mouthpiece.”
D. “I should use it once a day.”
Answer: B
Rationale: The incentive spirometer promotes
,deep inspiration to prevent atelectasis. It should be
used 10 times per hour while awake.
3. The nurse is turning a patient with a stage II
pressure injury. Which intervention is most
important?
A. Use pillows to elevate bony prominences.
B. Massage over reddened areas to increase blood
flow.
C. Apply adhesive bandages tightly.
D. Keep the patient on the affected side.
Answer: A
Rationale: Pillows reduce pressure. Massage over
reddened areas can damage capillaries and worsen
the injury.
4. The nurse notices a patient’s urinary catheter
drainage bag is empty for 4 hours. What should the
nurse do first?
A. Irrigate the catheter.
B. Check for kinks in the tubing.
C. Notify the provider.
D. Increase the IV fluids.
Answer: B
Rationale: A kinked or obstructed catheter is the
most common cause of no output. Always assess
before intervening or notifying the provider.
,5. The nurse assists a patient from bed to
wheelchair. Which action ensures safety?
A. Lock both bed and wheelchair wheels.
B. Keep bed height higher than the wheelchair.
C. Stand behind the patient during transfer.
D. Remove the footrests after transfer.
Answer: A
Rationale: Always lock both sets of wheels to
prevent movement during transfer.
6. The nurse is preparing to bathe a client with
right-sided weakness. What should the nurse do?
A. Wash the unaffected side first.
B. Wash the affected side first.
C. Let the patient perform all self-care.
D. Keep the water very hot to clean thoroughly.
Answer: A
Rationale: Washing the unaffected side first helps
build confidence and allows the nurse to assess the
affected side last, minimizing fatigue.
7. The nurse should include which teaching when
instructing a client about proper body mechanics?
A. Keep feet close together when lifting.
B. Bend at the waist when picking up objects.
, C. Use the legs, not the back, to lift.
D. Hold items away from the body for balance.
Answer: C
Rationale: Leg muscles are stronger and protect
the back from injury. Keep objects close to the
body and feet shoulder-width apart.
8. A patient who is on bed rest reports
constipation. What nursing action is most
appropriate?
A. Increase fluid intake and ambulation if possible.
B. Decrease fiber intake.
C. Administer an enema immediately.
D. Encourage bedpan use only twice a day.
Answer: A
Rationale: Fluids, mobility, and fiber improve
bowel function. Enemas are last-resort
interventions.
9. Which assessment finding requires the nurse’s
immediate attention in a patient receiving oxygen
therapy?
A. Dry nasal mucosa
B. Respiratory rate of 24
C. Oxygen tubing disconnected
D. Patient reports dizziness when ambulating
— Batch 1 (Basic Care &
Comfort)
1. A nurse is providing mouth care to an
unconscious patient. What action is most
important?
A. Use lemon-glycerin swabs to clean the mouth.
B. Place the patient in a side-lying position.
C. Rinse with large amounts of water.
D. Use firm pressure with the toothbrush.
Answer: B
Rationale: The side-lying position prevents
aspiration during oral care. Lemon-glycerin swabs
cause mucosal dryness, and large amounts of
water increase aspiration risk.
2. The nurse is teaching a patient about proper use
of an incentive spirometer. Which statement
indicates correct understanding?
A. “I’ll blow into it as hard as I can.”
B. “I’ll inhale slowly and deeply.”
C. “I’ll exhale quickly into the mouthpiece.”
D. “I should use it once a day.”
Answer: B
Rationale: The incentive spirometer promotes
,deep inspiration to prevent atelectasis. It should be
used 10 times per hour while awake.
3. The nurse is turning a patient with a stage II
pressure injury. Which intervention is most
important?
A. Use pillows to elevate bony prominences.
B. Massage over reddened areas to increase blood
flow.
C. Apply adhesive bandages tightly.
D. Keep the patient on the affected side.
Answer: A
Rationale: Pillows reduce pressure. Massage over
reddened areas can damage capillaries and worsen
the injury.
4. The nurse notices a patient’s urinary catheter
drainage bag is empty for 4 hours. What should the
nurse do first?
A. Irrigate the catheter.
B. Check for kinks in the tubing.
C. Notify the provider.
D. Increase the IV fluids.
Answer: B
Rationale: A kinked or obstructed catheter is the
most common cause of no output. Always assess
before intervening or notifying the provider.
,5. The nurse assists a patient from bed to
wheelchair. Which action ensures safety?
A. Lock both bed and wheelchair wheels.
B. Keep bed height higher than the wheelchair.
C. Stand behind the patient during transfer.
D. Remove the footrests after transfer.
Answer: A
Rationale: Always lock both sets of wheels to
prevent movement during transfer.
6. The nurse is preparing to bathe a client with
right-sided weakness. What should the nurse do?
A. Wash the unaffected side first.
B. Wash the affected side first.
C. Let the patient perform all self-care.
D. Keep the water very hot to clean thoroughly.
Answer: A
Rationale: Washing the unaffected side first helps
build confidence and allows the nurse to assess the
affected side last, minimizing fatigue.
7. The nurse should include which teaching when
instructing a client about proper body mechanics?
A. Keep feet close together when lifting.
B. Bend at the waist when picking up objects.
, C. Use the legs, not the back, to lift.
D. Hold items away from the body for balance.
Answer: C
Rationale: Leg muscles are stronger and protect
the back from injury. Keep objects close to the
body and feet shoulder-width apart.
8. A patient who is on bed rest reports
constipation. What nursing action is most
appropriate?
A. Increase fluid intake and ambulation if possible.
B. Decrease fiber intake.
C. Administer an enema immediately.
D. Encourage bedpan use only twice a day.
Answer: A
Rationale: Fluids, mobility, and fiber improve
bowel function. Enemas are last-resort
interventions.
9. Which assessment finding requires the nurse’s
immediate attention in a patient receiving oxygen
therapy?
A. Dry nasal mucosa
B. Respiratory rate of 24
C. Oxygen tubing disconnected
D. Patient reports dizziness when ambulating
