NCLEX-RN Practice Questions: Nursing Fundamentals
Single-Best-Answer Questions
1)
A 72-year-old postoperative client (abdominal surgery, POD 2)
reports a new temperature of 38.6°C (101.5°F) and
serosanguinous drainage on the incision. The nurse notes the
client is tachycardic (HR 110) but denies pain. Which action
should the nurse take first?
A. Remove the surgical dressing and assess the incision.
B. Administer PRN acetaminophen for fever.
C. Notify the surgeon of possible wound infection.
D. Obtain blood cultures and start empiric IV antibiotics per
protocol.
CJMM:
Recognize cues: fever, tachycardia, drainage (infection signs).
Analyze: POD 2—could be early infection or inflammatory
response; immediate assessment required.
Decide: gather more data before invasive interventions.
Act: remove dressing and inspect wound.
Evaluate: determine need for cultures/antibiotics after
assessment.
Correct answer: A
,Rationale:
A — Correct. First step is to assess the wound directly to
confirm appearance, amount/type of drainage, erythema, or
dehiscence. Assessment yields data needed to prioritize next
steps.
B — Incorrect. Treating fever without assessing source delays
diagnosis and management; acetaminophen may mask fever
and impede assessment.
C — Incorrect. Notifying the surgeon is appropriate if
assessment suggests infection, but first the nurse must assess
and collect objective data.
D — Incorrect. Obtaining cultures/starting antibiotics may be
indicated if infection is confirmed; do not start empiric IV
antibiotics or invasive tests before assessment and orders.
2)
A nurse prepares to remove a Foley catheter from an adult male
for whom the catheter was placed 48 hours earlier and for
urinary retention. Which action should the nurse perform
before catheter removal?
A. Clamp the catheter for 4 hours to retrain bladder.
B. Check the client’s urine output and document the last
voiding time.
C. Inflate the balloon with 10 mL of sterile water to check for
leakage.
,D. Administer a bolus of 500 mL IV fluid to promote urine
production.
CJMM:
Recognize cues: timing and indication for removal.
Analyze: catheter in 48 hrs for retention—assess readiness.
Decide: verify urine output history and bladder function.
Act: review recent outputs and any voiding attempts.
Evaluate: proceed with removal if outputs adequate and
ordered.
Correct answer: B
Rationale:
B — Correct. Before removal, confirm urine output trends and
when the client last voided to anticipate post-removal urinary
retention risk and to document baseline.
A — Incorrect. Routine clamping is not recommended to
“retrain” bladder; clamping may increase risk of retention and
CAUTI.
C — Incorrect. Balloon is already inflated to secure catheter;
you don’t inflate to “check leakage.” Testing balloon integrity
involves unlocking and withdrawal of water, but not inflating
additional volume.
D — Incorrect. Administering IV fluid bolus solely to promote
urine production is inappropriate without indication and could
cause fluid overload.
, 3)
A client with COPD uses oxygen at 2 L/min via nasal cannula.
The client repeatedly lights a cigarette in the room despite “no
smoking” signs. Which action should the nurse take first?
A. Remove the oxygen source immediately and explain the fire
risk.
B. Place the client on continuous pulse oximetry and observe
closely.
C. Speak privately to the client about hospital policy and offer
smoking cessation resources.
D. Notify security to remove the client from the unit.
CJMM:
Recognize cues: oxygen therapy + smoking = immediate fire
hazard.
Analyze: safety risk to client and others—action required now.
Decide: remove oxygen to eliminate oxygen-enriched
environment and reduce ignition risk.
Act: remove oxygen source and secure client safety, then
educate.
Evaluate: ensure oxygen removed, client safe, and smoke
extinguished.
Correct answer: A
Rationale:
A — Correct. Immediate removal of the oxygen source reduces
fire risk. Safety of client and others is priority. After immediate
Single-Best-Answer Questions
1)
A 72-year-old postoperative client (abdominal surgery, POD 2)
reports a new temperature of 38.6°C (101.5°F) and
serosanguinous drainage on the incision. The nurse notes the
client is tachycardic (HR 110) but denies pain. Which action
should the nurse take first?
A. Remove the surgical dressing and assess the incision.
B. Administer PRN acetaminophen for fever.
C. Notify the surgeon of possible wound infection.
D. Obtain blood cultures and start empiric IV antibiotics per
protocol.
CJMM:
Recognize cues: fever, tachycardia, drainage (infection signs).
Analyze: POD 2—could be early infection or inflammatory
response; immediate assessment required.
Decide: gather more data before invasive interventions.
Act: remove dressing and inspect wound.
Evaluate: determine need for cultures/antibiotics after
assessment.
Correct answer: A
,Rationale:
A — Correct. First step is to assess the wound directly to
confirm appearance, amount/type of drainage, erythema, or
dehiscence. Assessment yields data needed to prioritize next
steps.
B — Incorrect. Treating fever without assessing source delays
diagnosis and management; acetaminophen may mask fever
and impede assessment.
C — Incorrect. Notifying the surgeon is appropriate if
assessment suggests infection, but first the nurse must assess
and collect objective data.
D — Incorrect. Obtaining cultures/starting antibiotics may be
indicated if infection is confirmed; do not start empiric IV
antibiotics or invasive tests before assessment and orders.
2)
A nurse prepares to remove a Foley catheter from an adult male
for whom the catheter was placed 48 hours earlier and for
urinary retention. Which action should the nurse perform
before catheter removal?
A. Clamp the catheter for 4 hours to retrain bladder.
B. Check the client’s urine output and document the last
voiding time.
C. Inflate the balloon with 10 mL of sterile water to check for
leakage.
,D. Administer a bolus of 500 mL IV fluid to promote urine
production.
CJMM:
Recognize cues: timing and indication for removal.
Analyze: catheter in 48 hrs for retention—assess readiness.
Decide: verify urine output history and bladder function.
Act: review recent outputs and any voiding attempts.
Evaluate: proceed with removal if outputs adequate and
ordered.
Correct answer: B
Rationale:
B — Correct. Before removal, confirm urine output trends and
when the client last voided to anticipate post-removal urinary
retention risk and to document baseline.
A — Incorrect. Routine clamping is not recommended to
“retrain” bladder; clamping may increase risk of retention and
CAUTI.
C — Incorrect. Balloon is already inflated to secure catheter;
you don’t inflate to “check leakage.” Testing balloon integrity
involves unlocking and withdrawal of water, but not inflating
additional volume.
D — Incorrect. Administering IV fluid bolus solely to promote
urine production is inappropriate without indication and could
cause fluid overload.
, 3)
A client with COPD uses oxygen at 2 L/min via nasal cannula.
The client repeatedly lights a cigarette in the room despite “no
smoking” signs. Which action should the nurse take first?
A. Remove the oxygen source immediately and explain the fire
risk.
B. Place the client on continuous pulse oximetry and observe
closely.
C. Speak privately to the client about hospital policy and offer
smoking cessation resources.
D. Notify security to remove the client from the unit.
CJMM:
Recognize cues: oxygen therapy + smoking = immediate fire
hazard.
Analyze: safety risk to client and others—action required now.
Decide: remove oxygen to eliminate oxygen-enriched
environment and reduce ignition risk.
Act: remove oxygen source and secure client safety, then
educate.
Evaluate: ensure oxygen removed, client safe, and smoke
extinguished.
Correct answer: A
Rationale:
A — Correct. Immediate removal of the oxygen source reduces
fire risk. Safety of client and others is priority. After immediate
