NCLEX-RN Practice Questions: Nursing Fundamentals
Single-Best-Answer Questions
1 — Infection control (Standard & Transmission-based
precautions) — Single-best-answer
Stem: A client with active pulmonary tuberculosis is admitted.
Which PPE should the nurse don first before entering the
client’s room?
A. Surgical mask
B. N95 respirator (fit-tested)
C. Gloves
D. Gown
Correct Answer: B. N95 respirator (fit-tested)
Rationales:
• A. Surgical mask — Incorrect. Surgical masks do not
protect against airborne droplets of Mycobacterium
tuberculosis; they protect against large droplets only. Not
adequate for airborne precautions.
• B. N95 respirator (fit-tested) — Correct. TB is an airborne
infection; an N95 (or higher) respirator that is fit-tested
protects the nurse from inhaling infectious droplet nuclei.
Donning respiratory protection must occur before room
entry.
, • C. Gloves — Incorrect. Gloves protect hands from contact
contamination but are secondary for airborne diseases and
are not the first PPE to don in airborne precautions.
• D. Gown — Incorrect. Gown prevents clothing
contamination from contact with secretions but is not
primary for airborne protection and is not the first item to
don.
CJMM mapping:
• Recognize cues: Diagnosis = pulmonary TB → airborne risk.
• Analyze: Airborne precautions require respiratory
protection; priority is respiratory PPE.
• Decide: Use a fit-tested N95 prior to room entry.
• Act: Don N95 respirator, then eye protection/gown/gloves
as indicated.
• Evaluate: Monitor for correct fit and absence of leakage;
confirm adherence to airborne isolation protocol.
2 — Patient safety (falls prevention) — Single-best-answer
Stem: An 82-year-old client is forgetful, uses a walker but tries
to stand without assistance. The nurse implements fall-
prevention measures. Which intervention takes highest
priority?
A. Place the bed in the lowest position with the wheels locked.
B. Apply a posey vest restraint when the client attempts to
,stand.
C. Keep the room door open at all times for observation.
D. Offer the client toileting every 4–6 hours.
Correct Answer: A. Place the bed in the lowest position with
the wheels locked.
Rationales:
• A. Place bed low with wheels locked — Correct. Lowest
bed position and locking wheels are immediate
environmental modifications that reduce injury risk if a
patient attempts to rise unassisted; highest priority for fall
safety.
• B. Apply posey vest restraint — Incorrect. Restraints are
last-resort, require prescription and continuous
monitoring, and may increase harm (e.g., agitation, injury).
Not first-line for fall prevention.
• C. Keep door open — Incorrect. May aid observation but
does not directly prevent falls and compromises privacy.
Not the highest-priority safety measure.
• D. Offer toileting every 4–6 hours — Incorrect. Regular
toileting reduces fall risk related to urgent needs but
frequency should be individualized (e.g., hourly or PRN)
and is not more immediately protective than bed position.
CJMM mapping:
, • Recognize: Elderly, ambulation device, unassisted attempts
to stand → high fall risk.
• Analyze: Environmental factors and immediate safety
modifications reduce harm.
• Decide: Implement immediate environmental control (bed
down, locked).
• Act: Lower bed, lock wheels, place call light within reach,
ensure non-slip footwear.
• Evaluate: Reassess fall risk, observe for attempts to rise,
adjust plan.
3 — Documentation (legal & professional) — Single-best-
answer
Stem: Which documentation entry by the nurse most accurately
follows professional and legal standards?
A. “Client is noncompliant; refused medication again.”
B. “Client refused morning dose of lisinopril at 0800 after
education; discussed risks; MD notified per protocol.”
C. “Client very agitated—gave PRN sedative.”
D. “Client reports dizziness; probably orthostatic—will check
later.”
Correct Answer: B. “Client refused morning dose of lisinopril at
0800 after education; discussed risks; MD notified per
protocol.”
Single-Best-Answer Questions
1 — Infection control (Standard & Transmission-based
precautions) — Single-best-answer
Stem: A client with active pulmonary tuberculosis is admitted.
Which PPE should the nurse don first before entering the
client’s room?
A. Surgical mask
B. N95 respirator (fit-tested)
C. Gloves
D. Gown
Correct Answer: B. N95 respirator (fit-tested)
Rationales:
• A. Surgical mask — Incorrect. Surgical masks do not
protect against airborne droplets of Mycobacterium
tuberculosis; they protect against large droplets only. Not
adequate for airborne precautions.
• B. N95 respirator (fit-tested) — Correct. TB is an airborne
infection; an N95 (or higher) respirator that is fit-tested
protects the nurse from inhaling infectious droplet nuclei.
Donning respiratory protection must occur before room
entry.
, • C. Gloves — Incorrect. Gloves protect hands from contact
contamination but are secondary for airborne diseases and
are not the first PPE to don in airborne precautions.
• D. Gown — Incorrect. Gown prevents clothing
contamination from contact with secretions but is not
primary for airborne protection and is not the first item to
don.
CJMM mapping:
• Recognize cues: Diagnosis = pulmonary TB → airborne risk.
• Analyze: Airborne precautions require respiratory
protection; priority is respiratory PPE.
• Decide: Use a fit-tested N95 prior to room entry.
• Act: Don N95 respirator, then eye protection/gown/gloves
as indicated.
• Evaluate: Monitor for correct fit and absence of leakage;
confirm adherence to airborne isolation protocol.
2 — Patient safety (falls prevention) — Single-best-answer
Stem: An 82-year-old client is forgetful, uses a walker but tries
to stand without assistance. The nurse implements fall-
prevention measures. Which intervention takes highest
priority?
A. Place the bed in the lowest position with the wheels locked.
B. Apply a posey vest restraint when the client attempts to
,stand.
C. Keep the room door open at all times for observation.
D. Offer the client toileting every 4–6 hours.
Correct Answer: A. Place the bed in the lowest position with
the wheels locked.
Rationales:
• A. Place bed low with wheels locked — Correct. Lowest
bed position and locking wheels are immediate
environmental modifications that reduce injury risk if a
patient attempts to rise unassisted; highest priority for fall
safety.
• B. Apply posey vest restraint — Incorrect. Restraints are
last-resort, require prescription and continuous
monitoring, and may increase harm (e.g., agitation, injury).
Not first-line for fall prevention.
• C. Keep door open — Incorrect. May aid observation but
does not directly prevent falls and compromises privacy.
Not the highest-priority safety measure.
• D. Offer toileting every 4–6 hours — Incorrect. Regular
toileting reduces fall risk related to urgent needs but
frequency should be individualized (e.g., hourly or PRN)
and is not more immediately protective than bed position.
CJMM mapping:
, • Recognize: Elderly, ambulation device, unassisted attempts
to stand → high fall risk.
• Analyze: Environmental factors and immediate safety
modifications reduce harm.
• Decide: Implement immediate environmental control (bed
down, locked).
• Act: Lower bed, lock wheels, place call light within reach,
ensure non-slip footwear.
• Evaluate: Reassess fall risk, observe for attempts to rise,
adjust plan.
3 — Documentation (legal & professional) — Single-best-
answer
Stem: Which documentation entry by the nurse most accurately
follows professional and legal standards?
A. “Client is noncompliant; refused medication again.”
B. “Client refused morning dose of lisinopril at 0800 after
education; discussed risks; MD notified per protocol.”
C. “Client very agitated—gave PRN sedative.”
D. “Client reports dizziness; probably orthostatic—will check
later.”
Correct Answer: B. “Client refused morning dose of lisinopril at
0800 after education; discussed risks; MD notified per
protocol.”
