NCLEX RN FUNDAMENTALS OF NURSING PRACTICE ACTUAL
QUESTIONS, ANSWERS AND EXPLANATION| LATEST UPDATE
2025/2026
1. The nurse is completing the preoperative checklist for a patient scheduled for surgery. In
reviewing the chart, the nurse finds the consent has not been signed by the patient. When the
patient starts asking questions regarding the surgery, what is the next action the nurse should
take?
a. Have the patient sign the consent
b. Tell the patient all questions will be answered by the surgeon before the anesthesiologist
administers anesthetic
c. Contact the surgeon to inform them the patient has questions regarding the procedure
d. Answer all the patient's questions - ANSWER c. Contact the surgeon to inform them the
patient has questions regarding the procedure
>Before any invasive procedure, the surgeon must inform the patient of what the procedure
entails, the purpose for the procedure, and the potential risks associated with that procedure
before the consent is signed by the patient. (Hence the term "informed consent.") If the consent
has not been signed and the patient has questions, the healthcare provider has not reviewed
the procedure and risks involved and needs to do so before the procedure.
2. The nurse is caring for a patient who had an endoscopic total hysterectomy and is now
experiencing urinary retention. The nurse is preparing to contact the healthcare provider using
SBAR (situation background assessment recommendation). Which of the following questions is
a part of SBAR communication?
a. "Could you tell me what I need to do?"
b. "What do you need to know about the patient?"
c. "I believe the patient needs a urinary catheter."
d. "Why do you think the patient is unable to urinate?" - ANSWER c. "I believe the patient needs
a urinary catheter."
> Making a recommendation to the healthcare provider is part of SBAR.
,The following is an example of how the nurse could effectively use SBAR in this patient
situation:
• Situation: "Mrs. Jones is experiencing urinary retention."
• Background: "She had an endoscopic total hysterectomy."
• Assessment: "Her vital signs have been stable today. She is taking PO fluids but has had no
urine output in the last five hours. Her bladder is distended."
• Recommendation: "I recommend that you see her and we insert an indwelling urinary Foley
catheter and measure urine output every two hours."
4.A patient is recovering from a total abdominal hysterectomy. When assessed by the nurse
eight hours after the procedure, which of the following would the nurse identify as an early sign
of shock?
a. Restlessness
b. Warm, dry skin that is pale
c. Heart rate of 115 bpm
d. Urine output 50 mL/hr - ANSWER a. Restlessness
> Early signs of shock include restlessness, anxiousness, nervousness, and irritability. This is due
to the sympathetic nervous system release of epinephrine, which also decreases perfusion to
the skin causing pallor, coolness, and clamminess. Other signs of shock include hypotension and
confusion.
5. A patient is admitted to the emergency room complaining of shortness of breath. The nurse
knows the patient will be evaluated for hypoxia and anticipates the healthcare provider
ordering which test?
a. Complete blood cell count (CBC)
b. Sputum culture
c. Hemoglobin (Hgb)
d. Arterial blood gas (ABG) - ANSWER d. Arterial blood gas (ABG)
,> An ABG evaluates gas exchange in the lungs, which will provide the needed information
regarding oxygenation status. An arterial blood gas reveals pH, carbon dioxide and oxygen
partial pressures, bicarbonate level (HCO3-), and pH.
6. Emergency medical services brings an unconscious adult in to the emergency room. When
the nurse performs a rapid assessment, the location to check the pulse is:
a. Radial
b. Brachial
c. Femoral
d. Carotid - ANSWER d. Carotid
> Rapid assessment of an unconscious adult patient begins with checking circulation, which is
checked at the carotid artery. If a patient is hypotensive (decreased blood pressure), the most
likely place to be able to feel a pulse is the carotid artery.
7. A patient is admitted to the medical-surgical unit with methicillin-resistant staphylococcus
aureus (MRSA) of a wound. The nurse initiates contact precautions, which includes use of which
of the following?
a. Clean gown and gloves
b. N-95 respirator
c. Biohazard bin placed in the room
d. Negative airflow room - ANSWER a. Clean gown and gloves
> Contact isolation requires all people entering the room to follow standard precautions in
addition to wearing a clean (not sterile) gown and gloves. Other diseases that require contact
precautions include the following: norovirus, rotavirus, and Clostridium difficile. Additionally,
patients with draining wounds, uncontrolled secretions, pressure ulcers, generalized rash, and
ostomy bags/tubes also warrant contact precautions.
C is incorrect because linen and trash for this patient are not considered biohazardous.
8. A patient in the medical-surgical unit tells the nurse they haven't had a bowel movement in
two days. What is the first intervention the nurse should implement?
, a. Review the patient's medical record to determine normal bowel pattern
b. Offer prune juice with every meal
c. Call the healthcare provider to request an order for stool softener
d. Increase the patient's oral fluid intake - ANSWER a. Review the patient's medical record to
determine normal bowel pattern
> Bowel patterns can vary greatly in adults: three BMs weekly up to three BMs daily is
considered within normal range. Several factors can influence normal bowel patterns, including
surgery, stress, and opioid medications. The nurse should review the medical record to
determine the patient's normal bowel patterns prior to hospitalization.
9.The nurse encourages a patient with a history of heart failure to reduce energy expenditure by
alternating activity and rest. Which nursing process phase is this?
a. Diagnosis
b. Planning
c. Implementation
d. Evaluation - ANSWER C. Implementation
> Teaching a patient about alternating activity and rest is a component of patient education,
which falls into the implementation phase. This is an example of putting an individualized plan
into action. Other components of implementation include assisting with hygienic care,
promoting physical comfort, supporting respiratory and elimination functions, facilitating
ingestion of food/fluids, managing the patient's surroundings, promoting a therapeutic
relationship, and carrying out other therapeutic nursing activities.
10. The nurse on the medical-surgical unit is interested in implementing evidence-based
practice. The nurse knows when evidence-based practice is utilized:
a. National health agencies create clinical practice guidelines that must be used.
b. Findings from randomized trials are used to plan care.
c. Clinical decision-making and nursing judgment are used to find which evidence works for
each specific situation in clinical practice.
d. Nursing interventions are statistically analyzed by a nurse in relation to patient outcomes to
discover evidence for appropriate patient interventions. - ANSWER c. Clinical decision-making
QUESTIONS, ANSWERS AND EXPLANATION| LATEST UPDATE
2025/2026
1. The nurse is completing the preoperative checklist for a patient scheduled for surgery. In
reviewing the chart, the nurse finds the consent has not been signed by the patient. When the
patient starts asking questions regarding the surgery, what is the next action the nurse should
take?
a. Have the patient sign the consent
b. Tell the patient all questions will be answered by the surgeon before the anesthesiologist
administers anesthetic
c. Contact the surgeon to inform them the patient has questions regarding the procedure
d. Answer all the patient's questions - ANSWER c. Contact the surgeon to inform them the
patient has questions regarding the procedure
>Before any invasive procedure, the surgeon must inform the patient of what the procedure
entails, the purpose for the procedure, and the potential risks associated with that procedure
before the consent is signed by the patient. (Hence the term "informed consent.") If the consent
has not been signed and the patient has questions, the healthcare provider has not reviewed
the procedure and risks involved and needs to do so before the procedure.
2. The nurse is caring for a patient who had an endoscopic total hysterectomy and is now
experiencing urinary retention. The nurse is preparing to contact the healthcare provider using
SBAR (situation background assessment recommendation). Which of the following questions is
a part of SBAR communication?
a. "Could you tell me what I need to do?"
b. "What do you need to know about the patient?"
c. "I believe the patient needs a urinary catheter."
d. "Why do you think the patient is unable to urinate?" - ANSWER c. "I believe the patient needs
a urinary catheter."
> Making a recommendation to the healthcare provider is part of SBAR.
,The following is an example of how the nurse could effectively use SBAR in this patient
situation:
• Situation: "Mrs. Jones is experiencing urinary retention."
• Background: "She had an endoscopic total hysterectomy."
• Assessment: "Her vital signs have been stable today. She is taking PO fluids but has had no
urine output in the last five hours. Her bladder is distended."
• Recommendation: "I recommend that you see her and we insert an indwelling urinary Foley
catheter and measure urine output every two hours."
4.A patient is recovering from a total abdominal hysterectomy. When assessed by the nurse
eight hours after the procedure, which of the following would the nurse identify as an early sign
of shock?
a. Restlessness
b. Warm, dry skin that is pale
c. Heart rate of 115 bpm
d. Urine output 50 mL/hr - ANSWER a. Restlessness
> Early signs of shock include restlessness, anxiousness, nervousness, and irritability. This is due
to the sympathetic nervous system release of epinephrine, which also decreases perfusion to
the skin causing pallor, coolness, and clamminess. Other signs of shock include hypotension and
confusion.
5. A patient is admitted to the emergency room complaining of shortness of breath. The nurse
knows the patient will be evaluated for hypoxia and anticipates the healthcare provider
ordering which test?
a. Complete blood cell count (CBC)
b. Sputum culture
c. Hemoglobin (Hgb)
d. Arterial blood gas (ABG) - ANSWER d. Arterial blood gas (ABG)
,> An ABG evaluates gas exchange in the lungs, which will provide the needed information
regarding oxygenation status. An arterial blood gas reveals pH, carbon dioxide and oxygen
partial pressures, bicarbonate level (HCO3-), and pH.
6. Emergency medical services brings an unconscious adult in to the emergency room. When
the nurse performs a rapid assessment, the location to check the pulse is:
a. Radial
b. Brachial
c. Femoral
d. Carotid - ANSWER d. Carotid
> Rapid assessment of an unconscious adult patient begins with checking circulation, which is
checked at the carotid artery. If a patient is hypotensive (decreased blood pressure), the most
likely place to be able to feel a pulse is the carotid artery.
7. A patient is admitted to the medical-surgical unit with methicillin-resistant staphylococcus
aureus (MRSA) of a wound. The nurse initiates contact precautions, which includes use of which
of the following?
a. Clean gown and gloves
b. N-95 respirator
c. Biohazard bin placed in the room
d. Negative airflow room - ANSWER a. Clean gown and gloves
> Contact isolation requires all people entering the room to follow standard precautions in
addition to wearing a clean (not sterile) gown and gloves. Other diseases that require contact
precautions include the following: norovirus, rotavirus, and Clostridium difficile. Additionally,
patients with draining wounds, uncontrolled secretions, pressure ulcers, generalized rash, and
ostomy bags/tubes also warrant contact precautions.
C is incorrect because linen and trash for this patient are not considered biohazardous.
8. A patient in the medical-surgical unit tells the nurse they haven't had a bowel movement in
two days. What is the first intervention the nurse should implement?
, a. Review the patient's medical record to determine normal bowel pattern
b. Offer prune juice with every meal
c. Call the healthcare provider to request an order for stool softener
d. Increase the patient's oral fluid intake - ANSWER a. Review the patient's medical record to
determine normal bowel pattern
> Bowel patterns can vary greatly in adults: three BMs weekly up to three BMs daily is
considered within normal range. Several factors can influence normal bowel patterns, including
surgery, stress, and opioid medications. The nurse should review the medical record to
determine the patient's normal bowel patterns prior to hospitalization.
9.The nurse encourages a patient with a history of heart failure to reduce energy expenditure by
alternating activity and rest. Which nursing process phase is this?
a. Diagnosis
b. Planning
c. Implementation
d. Evaluation - ANSWER C. Implementation
> Teaching a patient about alternating activity and rest is a component of patient education,
which falls into the implementation phase. This is an example of putting an individualized plan
into action. Other components of implementation include assisting with hygienic care,
promoting physical comfort, supporting respiratory and elimination functions, facilitating
ingestion of food/fluids, managing the patient's surroundings, promoting a therapeutic
relationship, and carrying out other therapeutic nursing activities.
10. The nurse on the medical-surgical unit is interested in implementing evidence-based
practice. The nurse knows when evidence-based practice is utilized:
a. National health agencies create clinical practice guidelines that must be used.
b. Findings from randomized trials are used to plan care.
c. Clinical decision-making and nursing judgment are used to find which evidence works for
each specific situation in clinical practice.
d. Nursing interventions are statistically analyzed by a nurse in relation to patient outcomes to
discover evidence for appropriate patient interventions. - ANSWER c. Clinical decision-making
