NCLEX RN Fundamentals of Nursing
Exam 2 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026
Question 1
A nurse is preparing to administer oral medications to a client. Which action is
most important for preventing medication errors?
A. Ask the client to state the medication name.
B. Compare the medication label with the medication administration record
three times.
C. Place all medications in a medication cup before entering the room.
D. Document administration before giving the medication.
Answer: B. Compare the medication label with the medication administration
record three times.
Rationale: Comparing the medication label with the medication
administration record according to medication-safety procedures helps
prevent wrong-medication, wrong-dose, and wrong-client errors.
Question 2
A client is at high risk for falls. Which intervention should the nurse implement
first?
A. Place the client in a room near the nurses' station.
B. Keep the bed in the lowest position.
C. Apply a vest restraint.
D. Encourage the client to remain in bed at all times.
,Answer: B. Keep the bed in the lowest position.
Rationale: A low bed reduces the distance a client could fall and is a basic fall-
prevention intervention. Restraints should not be used routinely for fall
prevention.
Question 3
Which finding indicates that a client may be experiencing hypoxia?
A. Oxygen saturation of 98%
B. Respiratory rate of 16/min
C. Restlessness and confusion
D. Warm, dry skin
Answer: C. Restlessness and confusion.
Rationale: Early manifestations of hypoxia include restlessness, anxiety,
irritability, and confusion. These changes may occur before severe oxygen
desaturation becomes apparent.
Question 4
A nurse is caring for a client who has dysphagia after a stroke. Which action is
appropriate?
A. Offer thin liquids first.
B. Position the client upright during meals.
C. Encourage the client to drink through a straw.
D. Place food on the affected side of the mouth.
Answer: B. Position the client upright during meals.
Rationale: Upright positioning decreases the risk of aspiration. Food and
liquids should be administered according to the prescribed swallowing
recommendations.
Question 5
,Which assessment finding requires immediate intervention?
A. Blood pressure of 118/72 mm Hg
B. Respiratory rate of 8/min
C. Temperature of 37.1°C (98.8°F)
D. Pulse of 82/min
Answer: B. Respiratory rate of 8/min.
Rationale: A respiratory rate of 8/min indicates significant respiratory
depression and can compromise oxygenation and ventilation. The nurse
should assess the client immediately and intervene according to the clinical
situation.
Question 6
A nurse is performing hand hygiene using alcohol-based hand rub. When
should the nurse use soap and water instead?
A. After taking a blood pressure
B. Before touching intact skin
C. When hands are visibly soiled
D. After talking with a client
Answer: C. When hands are visibly soiled.
Rationale: Soap and water should be used when hands are visibly dirty or
contaminated. Alcohol-based hand rub is appropriate in many other clinical
situations when hands are not visibly soiled.
Question 7
A client reports pain rated 8 on a 0-to-10 scale. What should the nurse do first?
A. Tell the client that the prescribed medication will be given soon.
B. Assess the characteristics and location of the pain.
C. Encourage the client to ignore the pain.
D. Document the pain as severe without further assessment.
, Answer: B. Assess the characteristics and location of the pain.
Rationale: Pain assessment should occur before selecting or evaluating
interventions. The nurse should determine location, quality, intensity, timing,
aggravating factors, and associated symptoms.
Question 8
Which nursing action demonstrates appropriate use of standard precautions?
A. Wearing sterile gloves for every client interaction
B. Wearing gloves when contact with blood or body fluids is anticipated
C. Using an N95 respirator for every client
D. Placing every client in an isolation room
Answer: B. Wearing gloves when contact with blood or body fluids is
anticipated.
Rationale: Standard precautions are based on the potential exposure to
blood, body fluids, nonintact skin, or mucous membranes. Gloves are used
when such exposure is anticipated.
Question 9
A nurse is transferring a client from bed to a wheelchair. Which action is safest?
A. Place the wheelchair several feet from the bed.
B. Lock the wheelchair wheels before transferring the client.
C. Leave the wheelchair footrests in place during transfer.
D. Have the client hold onto the nurse's neck.
Answer: B. Lock the wheelchair wheels before transferring the client.
Rationale: Locking the wheelchair prevents it from moving during transfer
and reduces the risk of injury. The nurse should use proper body mechanics
and transfer techniques.
Question 10
Exam 2 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026
Question 1
A nurse is preparing to administer oral medications to a client. Which action is
most important for preventing medication errors?
A. Ask the client to state the medication name.
B. Compare the medication label with the medication administration record
three times.
C. Place all medications in a medication cup before entering the room.
D. Document administration before giving the medication.
Answer: B. Compare the medication label with the medication administration
record three times.
Rationale: Comparing the medication label with the medication
administration record according to medication-safety procedures helps
prevent wrong-medication, wrong-dose, and wrong-client errors.
Question 2
A client is at high risk for falls. Which intervention should the nurse implement
first?
A. Place the client in a room near the nurses' station.
B. Keep the bed in the lowest position.
C. Apply a vest restraint.
D. Encourage the client to remain in bed at all times.
,Answer: B. Keep the bed in the lowest position.
Rationale: A low bed reduces the distance a client could fall and is a basic fall-
prevention intervention. Restraints should not be used routinely for fall
prevention.
Question 3
Which finding indicates that a client may be experiencing hypoxia?
A. Oxygen saturation of 98%
B. Respiratory rate of 16/min
C. Restlessness and confusion
D. Warm, dry skin
Answer: C. Restlessness and confusion.
Rationale: Early manifestations of hypoxia include restlessness, anxiety,
irritability, and confusion. These changes may occur before severe oxygen
desaturation becomes apparent.
Question 4
A nurse is caring for a client who has dysphagia after a stroke. Which action is
appropriate?
A. Offer thin liquids first.
B. Position the client upright during meals.
C. Encourage the client to drink through a straw.
D. Place food on the affected side of the mouth.
Answer: B. Position the client upright during meals.
Rationale: Upright positioning decreases the risk of aspiration. Food and
liquids should be administered according to the prescribed swallowing
recommendations.
Question 5
,Which assessment finding requires immediate intervention?
A. Blood pressure of 118/72 mm Hg
B. Respiratory rate of 8/min
C. Temperature of 37.1°C (98.8°F)
D. Pulse of 82/min
Answer: B. Respiratory rate of 8/min.
Rationale: A respiratory rate of 8/min indicates significant respiratory
depression and can compromise oxygenation and ventilation. The nurse
should assess the client immediately and intervene according to the clinical
situation.
Question 6
A nurse is performing hand hygiene using alcohol-based hand rub. When
should the nurse use soap and water instead?
A. After taking a blood pressure
B. Before touching intact skin
C. When hands are visibly soiled
D. After talking with a client
Answer: C. When hands are visibly soiled.
Rationale: Soap and water should be used when hands are visibly dirty or
contaminated. Alcohol-based hand rub is appropriate in many other clinical
situations when hands are not visibly soiled.
Question 7
A client reports pain rated 8 on a 0-to-10 scale. What should the nurse do first?
A. Tell the client that the prescribed medication will be given soon.
B. Assess the characteristics and location of the pain.
C. Encourage the client to ignore the pain.
D. Document the pain as severe without further assessment.
, Answer: B. Assess the characteristics and location of the pain.
Rationale: Pain assessment should occur before selecting or evaluating
interventions. The nurse should determine location, quality, intensity, timing,
aggravating factors, and associated symptoms.
Question 8
Which nursing action demonstrates appropriate use of standard precautions?
A. Wearing sterile gloves for every client interaction
B. Wearing gloves when contact with blood or body fluids is anticipated
C. Using an N95 respirator for every client
D. Placing every client in an isolation room
Answer: B. Wearing gloves when contact with blood or body fluids is
anticipated.
Rationale: Standard precautions are based on the potential exposure to
blood, body fluids, nonintact skin, or mucous membranes. Gloves are used
when such exposure is anticipated.
Question 9
A nurse is transferring a client from bed to a wheelchair. Which action is safest?
A. Place the wheelchair several feet from the bed.
B. Lock the wheelchair wheels before transferring the client.
C. Leave the wheelchair footrests in place during transfer.
D. Have the client hold onto the nurse's neck.
Answer: B. Lock the wheelchair wheels before transferring the client.
Rationale: Locking the wheelchair prevents it from moving during transfer
and reduces the risk of injury. The nurse should use proper body mechanics
and transfer techniques.
Question 10
