NCLEX RN Fundamentals of Nursing
Exam 1 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026
1. A nurse is preparing to provide care to a client. Which action is most
important for preventing the transmission of infection?
A. Wearing gloves for every client interaction
B. Performing hand hygiene before and after client contact
C. Keeping the client's room door closed
D. Wearing a surgical mask during routine care
Answer: Performing hand hygiene before and after client contact
Rationale: Hand hygiene is the most effective measure for preventing the
transmission of microorganisms in healthcare settings.
2. Which position is best for a client experiencing difficulty breathing?
A. Supine
B. Prone
C. High-Fowler's
D. Trendelenburg
Answer: High-Fowler's
Rationale: High-Fowler's position promotes maximal lung expansion and can
improve ventilation in clients with respiratory distress.
3. A nurse is caring for a client who has an increased risk for falls. Which
intervention is appropriate?
A. Keep the bed in the highest position
B. Place frequently used items within reach
,C. Keep all four side rails raised
D. Encourage the client to ambulate independently
Answer: Place frequently used items within reach
Rationale: Keeping necessary items within reach reduces unnecessary
stretching or climbing and decreases fall risk.
4. Which assessment finding should the nurse report immediately?
A. Respiratory rate of 16/min
B. Blood pressure of 118/72 mm Hg
C. Oxygen saturation of 88%
D. Temperature of 37°C (98.6°F)
Answer: Oxygen saturation of 88%
Rationale: An oxygen saturation of 88% indicates hypoxemia and requires
prompt assessment and intervention.
5. A nurse is preparing to administer medication. Which action should be
performed first?
A. Document the medication administration
B. Identify the client using two identifiers
C. Dispose of the medication wrapper
D. Explain potential adverse effects
Answer: Identify the client using two identifiers
Rationale: Correct client identification is a fundamental medication-safety
measure and should occur before medication administration.
6. Which finding indicates that a client's airway is patent?
A. Absence of coughing
B. Clear, unobstructed breath sounds
C. Respiratory rate of 8/min
D. Cyanotic nail beds
Answer: Clear, unobstructed breath sounds
, Rationale: Clear breath sounds and effective airflow indicate that air is
moving through an open airway.
7. A nurse is assessing a client's pain. Which question is most appropriate?
A. "You aren't having much pain, are you?"
B. "Where does it hurt?"
C. "Why are you having pain?"
D. "Is your pain tolerable?"
Answer: "Where does it hurt?"
Rationale: Open-ended, objective questions encourage the client to describe
the pain accurately without leading the response.
8. Which intervention is appropriate when caring for a client with
dysphagia?
A. Encourage the client to drink quickly
B. Place the client upright during meals
C. Offer thin liquids first
D. Have the client lie down after eating
Answer: Place the client upright during meals
Rationale: Upright positioning reduces the risk of aspiration during
swallowing.
9. Which finding is characteristic of dehydration?
A. Bounding pulse
B. Moist mucous membranes
C. Concentrated urine
D. Peripheral edema
Answer: Concentrated urine
Rationale: Dehydration causes the kidneys to conserve water, resulting in
decreased urine output and concentrated urine.
10.Which nursing intervention helps prevent pressure injuries?
Exam 1 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026
1. A nurse is preparing to provide care to a client. Which action is most
important for preventing the transmission of infection?
A. Wearing gloves for every client interaction
B. Performing hand hygiene before and after client contact
C. Keeping the client's room door closed
D. Wearing a surgical mask during routine care
Answer: Performing hand hygiene before and after client contact
Rationale: Hand hygiene is the most effective measure for preventing the
transmission of microorganisms in healthcare settings.
2. Which position is best for a client experiencing difficulty breathing?
A. Supine
B. Prone
C. High-Fowler's
D. Trendelenburg
Answer: High-Fowler's
Rationale: High-Fowler's position promotes maximal lung expansion and can
improve ventilation in clients with respiratory distress.
3. A nurse is caring for a client who has an increased risk for falls. Which
intervention is appropriate?
A. Keep the bed in the highest position
B. Place frequently used items within reach
,C. Keep all four side rails raised
D. Encourage the client to ambulate independently
Answer: Place frequently used items within reach
Rationale: Keeping necessary items within reach reduces unnecessary
stretching or climbing and decreases fall risk.
4. Which assessment finding should the nurse report immediately?
A. Respiratory rate of 16/min
B. Blood pressure of 118/72 mm Hg
C. Oxygen saturation of 88%
D. Temperature of 37°C (98.6°F)
Answer: Oxygen saturation of 88%
Rationale: An oxygen saturation of 88% indicates hypoxemia and requires
prompt assessment and intervention.
5. A nurse is preparing to administer medication. Which action should be
performed first?
A. Document the medication administration
B. Identify the client using two identifiers
C. Dispose of the medication wrapper
D. Explain potential adverse effects
Answer: Identify the client using two identifiers
Rationale: Correct client identification is a fundamental medication-safety
measure and should occur before medication administration.
6. Which finding indicates that a client's airway is patent?
A. Absence of coughing
B. Clear, unobstructed breath sounds
C. Respiratory rate of 8/min
D. Cyanotic nail beds
Answer: Clear, unobstructed breath sounds
, Rationale: Clear breath sounds and effective airflow indicate that air is
moving through an open airway.
7. A nurse is assessing a client's pain. Which question is most appropriate?
A. "You aren't having much pain, are you?"
B. "Where does it hurt?"
C. "Why are you having pain?"
D. "Is your pain tolerable?"
Answer: "Where does it hurt?"
Rationale: Open-ended, objective questions encourage the client to describe
the pain accurately without leading the response.
8. Which intervention is appropriate when caring for a client with
dysphagia?
A. Encourage the client to drink quickly
B. Place the client upright during meals
C. Offer thin liquids first
D. Have the client lie down after eating
Answer: Place the client upright during meals
Rationale: Upright positioning reduces the risk of aspiration during
swallowing.
9. Which finding is characteristic of dehydration?
A. Bounding pulse
B. Moist mucous membranes
C. Concentrated urine
D. Peripheral edema
Answer: Concentrated urine
Rationale: Dehydration causes the kidneys to conserve water, resulting in
decreased urine output and concentrated urine.
10.Which nursing intervention helps prevent pressure injuries?
