NCLEX RN Fundamentals of Nursing
Exam 3 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026
1. A nurse is assessing a client who reports shortness of breath. Which
assessment finding requires immediate intervention?
A. Respiratory rate of 20/min
B. Oxygen saturation of 88%
C. Temperature of 37.2°C (99°F)
D. Heart rate of 82/min
Answer: Oxygen saturation of 88%
Rationale: An oxygen saturation of 88% indicates hypoxemia and requires
prompt assessment and intervention, especially when accompanied by
dyspnea.
2. Which action should the nurse take when measuring a client's blood
pressure?
A. Place the cuff over clothing
B. Use a cuff that covers approximately 80% of the arm circumference
C. Position the arm below heart level
D. Have the client talk during the measurement
Answer: Use a cuff that covers approximately 80% of the arm circumference
Rationale: An appropriately sized cuff improves accuracy. A cuff that is too
small can produce a falsely elevated reading.
3. A nurse is caring for a client at risk for falls. Which intervention is most
appropriate?
,A. Keep the bed in the highest position
B. Keep frequently used items within reach
C. Encourage the client to walk independently
D. Keep all four side rails raised
Answer: Keep frequently used items within reach
Rationale: Keeping needed items within reach reduces unnecessary attempts
to get out of bed and helps prevent falls.
4. Which finding is most concerning when assessing a postoperative client?
A. Pain rated 5/10
B. Temperature of 37.5°C (99.5°F)
C. Respiratory rate of 8/min
D. Blood pressure of 128/76 mm Hg
Answer: Respiratory rate of 8/min
Rationale: A respiratory rate of 8/min indicates respiratory depression and
requires immediate assessment and intervention.
5. 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 positioning promotes lung expansion and decreases
pressure from abdominal organs on the diaphragm.
6. A nurse is preparing to administer medication through an enteral feeding
tube. What should the nurse do first?
A. Crush all medications together
B. Verify tube placement according to facility policy
C. Mix medications with the feeding formula
D. Administer the medication immediately
Answer: Verify tube placement according to facility policy
, Rationale: Confirming appropriate tube placement helps prevent medication
or fluid from entering the respiratory tract.
7. Which finding indicates that a client may be dehydrated?
A. Bounding pulse
B. Moist mucous membranes
C. Concentrated urine
D. Increased urine output
Answer: Concentrated urine
Rationale: Concentrated urine, dry mucous membranes, tachycardia, and
decreased urine output are common manifestations of fluid volume deficit.
8. Which nursing action is appropriate when caring for a client with an
indwelling urinary catheter?
A. Keep the drainage bag above bladder level
B. Disconnect the system daily
C. Maintain a closed drainage system
D. Allow the tubing to rest on the floor
Answer: Maintain a closed drainage system
Rationale: Maintaining a closed system reduces the risk of introducing
microorganisms into the urinary tract.
9. A client has difficulty swallowing. Which intervention reduces the risk of
aspiration?
A. Place the client flat after meals
B. Encourage rapid eating
C. Keep the client upright during and after meals
D. Provide thin liquids only
Answer: Keep the client upright during and after meals
Rationale: Upright positioning facilitates swallowing and decreases the
likelihood of food or fluid entering the airway.
10.Which intervention is most appropriate for preventing pressure injuries?
Exam 3 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026
1. A nurse is assessing a client who reports shortness of breath. Which
assessment finding requires immediate intervention?
A. Respiratory rate of 20/min
B. Oxygen saturation of 88%
C. Temperature of 37.2°C (99°F)
D. Heart rate of 82/min
Answer: Oxygen saturation of 88%
Rationale: An oxygen saturation of 88% indicates hypoxemia and requires
prompt assessment and intervention, especially when accompanied by
dyspnea.
2. Which action should the nurse take when measuring a client's blood
pressure?
A. Place the cuff over clothing
B. Use a cuff that covers approximately 80% of the arm circumference
C. Position the arm below heart level
D. Have the client talk during the measurement
Answer: Use a cuff that covers approximately 80% of the arm circumference
Rationale: An appropriately sized cuff improves accuracy. A cuff that is too
small can produce a falsely elevated reading.
3. A nurse is caring for a client at risk for falls. Which intervention is most
appropriate?
,A. Keep the bed in the highest position
B. Keep frequently used items within reach
C. Encourage the client to walk independently
D. Keep all four side rails raised
Answer: Keep frequently used items within reach
Rationale: Keeping needed items within reach reduces unnecessary attempts
to get out of bed and helps prevent falls.
4. Which finding is most concerning when assessing a postoperative client?
A. Pain rated 5/10
B. Temperature of 37.5°C (99.5°F)
C. Respiratory rate of 8/min
D. Blood pressure of 128/76 mm Hg
Answer: Respiratory rate of 8/min
Rationale: A respiratory rate of 8/min indicates respiratory depression and
requires immediate assessment and intervention.
5. 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 positioning promotes lung expansion and decreases
pressure from abdominal organs on the diaphragm.
6. A nurse is preparing to administer medication through an enteral feeding
tube. What should the nurse do first?
A. Crush all medications together
B. Verify tube placement according to facility policy
C. Mix medications with the feeding formula
D. Administer the medication immediately
Answer: Verify tube placement according to facility policy
, Rationale: Confirming appropriate tube placement helps prevent medication
or fluid from entering the respiratory tract.
7. Which finding indicates that a client may be dehydrated?
A. Bounding pulse
B. Moist mucous membranes
C. Concentrated urine
D. Increased urine output
Answer: Concentrated urine
Rationale: Concentrated urine, dry mucous membranes, tachycardia, and
decreased urine output are common manifestations of fluid volume deficit.
8. Which nursing action is appropriate when caring for a client with an
indwelling urinary catheter?
A. Keep the drainage bag above bladder level
B. Disconnect the system daily
C. Maintain a closed drainage system
D. Allow the tubing to rest on the floor
Answer: Maintain a closed drainage system
Rationale: Maintaining a closed system reduces the risk of introducing
microorganisms into the urinary tract.
9. A client has difficulty swallowing. Which intervention reduces the risk of
aspiration?
A. Place the client flat after meals
B. Encourage rapid eating
C. Keep the client upright during and after meals
D. Provide thin liquids only
Answer: Keep the client upright during and after meals
Rationale: Upright positioning facilitates swallowing and decreases the
likelihood of food or fluid entering the airway.
10.Which intervention is most appropriate for preventing pressure injuries?
