Fundamentals of Nursing NCLEX Practice
Exam Set 9 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2025/2026 Q&A | Instant
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1. A nurse is caring for a patient who is confused and wandering.
Which is the most appropriate nursing intervention?
A. Restrain the patient with soft wrist restraints
B. Place the patient in a locked room
C. Use a bed and chair alarm
D. Administer a sedative as needed
Answer: C. Use a bed and chair alarm
Rationale: Bed and chair alarms alert staff when a patient attempts
to get up, preventing falls while avoiding unnecessary restraints.
2. Which is the best method to prevent the spread of infection in a
hospital setting?
A. Hand hygiene
B. Wearing gloves only when in contact with blood
C. Using antibiotics prophylactically
D. Wearing a mask at all times
Answer: A. Hand hygiene
Rationale: Hand hygiene is the single most effective way to prevent
healthcare-associated infections.
,3. A patient has a prescription for a 24-hour urine collection. Which
instruction is correct?
A. Start the collection with the first morning urine
B. Discard the first morning urine and collect all urine for 24 hours
C. Collect urine only during the daytime
D. Collect urine in separate containers each time
Answer: B. Discard the first morning urine and collect all urine for
24 hours
Rationale: Discarding the first morning urine ensures accurate
measurement for the full 24-hour period.
4. Which vital sign is the most reliable indicator of pain in a non-
verbal patient?
A. Temperature
B. Respiratory rate
C. Blood pressure
D. Heart rate
Answer: D. Heart rate
Rationale: Pain often triggers sympathetic responses, including
increased heart rate; monitoring vital signs helps detect discomfort in
non-verbal patients.
5. The nurse is teaching a patient about proper use of crutches.
Which instruction is correct?
A. Place crutches 6 inches in front and 6 inches to the side of the feet
B. Keep crutches 12 inches away from the body
C. Swing through the crutches instead of stepping with the injured
leg
D. Bear full weight on the axilla
,Answer: A. Place crutches 6 inches in front and 6 inches to the side
of the feet
Rationale: Correct crutch placement prevents falls and reduces strain;
weight should be on hands, not axilla.
6. A nurse is performing wound care on a surgical incision. Which
technique is essential?
A. Using sterile gloves and sterile supplies
B. Cleansing from the least contaminated to the most contaminated
area
C. Using tap water to irrigate the wound
D. Covering the wound loosely without dressing
Answer: A. Using sterile gloves and sterile supplies
Rationale: Sterile technique minimizes the risk of infection in surgical
wounds.
7. Which is the primary purpose of using an incentive spirometer?
A. Reduce the risk of atelectasis
B. Improve cardiac output
C. Decrease blood pressure
D. Promote digestion
Answer: A. Reduce the risk of atelectasis
Rationale: Incentive spirometry encourages deep breathing,
preventing alveolar collapse and improving oxygenation.
8. A nurse is caring for a patient on strict bed rest. Which
intervention helps prevent complications of immobility?
A. Encourage ambulation as tolerated
B. Apply tight restraints to prevent movement
, C. Limit fluids to avoid incontinence
D. Keep the patient in a supine position at all times
Answer: A. Encourage ambulation as tolerated
Rationale: Early mobilization reduces risk of pressure ulcers, venous
thromboembolism, and muscle atrophy.
9. Which action should a nurse take first when a patient develops
sudden shortness of breath?
A. Notify the healthcare provider
B. Assess respiratory status and oxygen saturation
C. Elevate the head of the bed
D. Administer prescribed bronchodilator
Answer: B. Assess respiratory status and oxygen saturation
Rationale: Assessing airway, breathing, and oxygenation is the first
step in emergency situations (ABCs).
10. A nurse is teaching a patient with a new colostomy. Which
instruction is correct?
A. Empty the pouch when it is one-quarter full
B. Wash the stoma with soap and water and dry thoroughly
C. Use adhesive remover sparingly
D. Avoid cutting the wafer to fit around the stoma
Answer: B. Wash the stoma with soap and water and dry
thoroughly
Rationale: Clean, dry skin prevents irritation and infection around the
stoma.
11. Which intervention is a priority for a patient with impaired skin
integrity due to pressure ulcers?
Exam Set 9 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2025/2026 Q&A | Instant
Download Pdf
1. A nurse is caring for a patient who is confused and wandering.
Which is the most appropriate nursing intervention?
A. Restrain the patient with soft wrist restraints
B. Place the patient in a locked room
C. Use a bed and chair alarm
D. Administer a sedative as needed
Answer: C. Use a bed and chair alarm
Rationale: Bed and chair alarms alert staff when a patient attempts
to get up, preventing falls while avoiding unnecessary restraints.
2. Which is the best method to prevent the spread of infection in a
hospital setting?
A. Hand hygiene
B. Wearing gloves only when in contact with blood
C. Using antibiotics prophylactically
D. Wearing a mask at all times
Answer: A. Hand hygiene
Rationale: Hand hygiene is the single most effective way to prevent
healthcare-associated infections.
,3. A patient has a prescription for a 24-hour urine collection. Which
instruction is correct?
A. Start the collection with the first morning urine
B. Discard the first morning urine and collect all urine for 24 hours
C. Collect urine only during the daytime
D. Collect urine in separate containers each time
Answer: B. Discard the first morning urine and collect all urine for
24 hours
Rationale: Discarding the first morning urine ensures accurate
measurement for the full 24-hour period.
4. Which vital sign is the most reliable indicator of pain in a non-
verbal patient?
A. Temperature
B. Respiratory rate
C. Blood pressure
D. Heart rate
Answer: D. Heart rate
Rationale: Pain often triggers sympathetic responses, including
increased heart rate; monitoring vital signs helps detect discomfort in
non-verbal patients.
5. The nurse is teaching a patient about proper use of crutches.
Which instruction is correct?
A. Place crutches 6 inches in front and 6 inches to the side of the feet
B. Keep crutches 12 inches away from the body
C. Swing through the crutches instead of stepping with the injured
leg
D. Bear full weight on the axilla
,Answer: A. Place crutches 6 inches in front and 6 inches to the side
of the feet
Rationale: Correct crutch placement prevents falls and reduces strain;
weight should be on hands, not axilla.
6. A nurse is performing wound care on a surgical incision. Which
technique is essential?
A. Using sterile gloves and sterile supplies
B. Cleansing from the least contaminated to the most contaminated
area
C. Using tap water to irrigate the wound
D. Covering the wound loosely without dressing
Answer: A. Using sterile gloves and sterile supplies
Rationale: Sterile technique minimizes the risk of infection in surgical
wounds.
7. Which is the primary purpose of using an incentive spirometer?
A. Reduce the risk of atelectasis
B. Improve cardiac output
C. Decrease blood pressure
D. Promote digestion
Answer: A. Reduce the risk of atelectasis
Rationale: Incentive spirometry encourages deep breathing,
preventing alveolar collapse and improving oxygenation.
8. A nurse is caring for a patient on strict bed rest. Which
intervention helps prevent complications of immobility?
A. Encourage ambulation as tolerated
B. Apply tight restraints to prevent movement
, C. Limit fluids to avoid incontinence
D. Keep the patient in a supine position at all times
Answer: A. Encourage ambulation as tolerated
Rationale: Early mobilization reduces risk of pressure ulcers, venous
thromboembolism, and muscle atrophy.
9. Which action should a nurse take first when a patient develops
sudden shortness of breath?
A. Notify the healthcare provider
B. Assess respiratory status and oxygen saturation
C. Elevate the head of the bed
D. Administer prescribed bronchodilator
Answer: B. Assess respiratory status and oxygen saturation
Rationale: Assessing airway, breathing, and oxygenation is the first
step in emergency situations (ABCs).
10. A nurse is teaching a patient with a new colostomy. Which
instruction is correct?
A. Empty the pouch when it is one-quarter full
B. Wash the stoma with soap and water and dry thoroughly
C. Use adhesive remover sparingly
D. Avoid cutting the wafer to fit around the stoma
Answer: B. Wash the stoma with soap and water and dry
thoroughly
Rationale: Clean, dry skin prevents irritation and infection around the
stoma.
11. Which intervention is a priority for a patient with impaired skin
integrity due to pressure ulcers?
