51 Fundamentals & Safety Practice Questions & Answers
Every Fundamentals & Safety practice question from the NCLEX-RN Practice Test, with the correct answer and a short explanation.
Start practice test →1. A charge nurse is assigning tasks on a medical unit. Which task is appropriate to delegate to unlicensed assistive personnel (UAP)?
- A.Assessing lung sounds on a newly admitted client
- B.Reinforcing teaching about a low-sodium diet
- C.Evaluating a client's response to a new pain medication
- D.Measuring vital signs on a stable client scheduled for discharge✓ Answer
UAP scope is limited to stable, predictable tasks such as vital signs on stable clients, ADLs, and I&O. Assessment, teaching, and evaluation require nursing judgment and cannot be delegated to UAP.
Source: NCLEX-RN Test Plan: Management of Care — Delegation; 5 Rights of Delegation (right task)Report a problem with this question
2. Which client is most appropriate to assign to a licensed practical/vocational nurse (LPN/LVN)?
- A.A client 1 hour post-op requiring the first assessment
- B.A stable client with a chronic wound who needs a dressing change✓ Answer
- C.A client requiring titration of an IV heparin drip
- D.A client newly diagnosed with diabetes who needs initial insulin teaching
LPN/LVN scope covers stable clients with predictable outcomes: sterile procedures, dressing changes, and reinforcing teaching. Initial teaching, first post-op assessment, and titrating high-alert IV drips require the RN.
Source: NCLEX-RN Test Plan: Management of Care — Scope of Practice (LPN/LVN)Report a problem with this question
3. A nurse delegates care of four clients. Which delegation requires the nurse to intervene?
- A.Asking the UAP to assist a stable client with morning hygiene
- B.Asking the LPN to insert a urinary catheter using sterile technique
- C.Asking the UAP to teach a client how to use an incentive spirometer✓ Answer
- D.Asking the LPN to administer an oral antihypertensive
Client teaching requires nursing judgment and cannot be delegated to UAP. Hygiene (UAP), oral meds (LPN), and sterile catheter insertion (LPN) are all within scope, so the teaching delegation must be corrected.
Source: NCLEX-RN Test Plan: Management of Care — Delegation (teaching not delegable to UAP)Report a problem with this question
4. A nurse receives report on four clients. Which client should the nurse assess first?
- A.A client anxious about being discharged later that day
- B.A client with new onset of stridor and increasing respiratory effort✓ Answer
- C.A client with a chronic pressure injury awaiting a dressing change
- D.A client reporting 6/10 incisional pain after abdominal surgery
Airway comes first in the ABC framework. New stridor with increasing respiratory effort signals a threatened airway and takes priority over pain, chronic wounds, and psychosocial anxiety.
Source: NCLEX-RN Test Plan: Prioritization — ABC (airway first)Report a problem with this question
5. Using Maslow's hierarchy, which client need should the nurse address first?
- A.A client with a dry oxygen mask reporting shortness of breath✓ Answer
- B.A client who feels lonely and wants to talk
- C.A client worried about the cost of hospitalization
- D.A client requesting a chaplain visit before surgery
Maslow prioritizes physiologic needs before psychosocial ones. Shortness of breath is an unmet oxygenation (physiologic) need and outranks spiritual, social, and financial concerns.
Source: NCLEX-RN Test Plan: Prioritization — Maslow (physiologic before psychosocial)Report a problem with this question
6. Which newly admitted client should the nurse plan to see first?
- A.A client with a blood glucose of 48 mg/dL and diaphoresis✓ Answer
- B.A client with stable chronic heart failure admitted for teaching
- C.A client with a healing fracture awaiting physical therapy
- D.A client with well-controlled hypertension due for morning meds
A blood glucose of 48 mg/dL with diaphoresis indicates symptomatic hypoglycemia—an acute, unstable, physiologic emergency—which is seen before stable or chronic clients.
Source: NCLEX-RN Test Plan: Prioritization — acute/unstable before chronic/stableReport a problem with this question
7. When applying the '5 Rights of Delegation,' which action best reflects the 'right supervision'?
- A.Delegating any task the UAP feels comfortable performing
- B.Following up to verify the task was completed and the outcome✓ Answer
- C.Assuming the task was done correctly because the UAP is experienced
- D.Documenting the task as complete before it is performed
Right supervision requires the delegating nurse to monitor, follow up, evaluate performance, and confirm the outcome. Delegation never transfers accountability away from the RN.
Source: NCLEX-RN Test Plan: Management of Care — 5 Rights of Delegation (right supervision)Report a problem with this question
8. A client is scheduled for surgery and asks about the risks of the procedure. What is the nurse's best action?
- A.Tell the client not to worry because the surgeon is skilled
- B.Explain the surgical risks and benefits in detail
- C.Ask the client to sign the consent form now
- D.Notify the surgeon so the provider can discuss the risks✓ Answer
Obtaining informed consent—explaining risks, benefits, and alternatives—is the provider's responsibility. The nurse witnesses the signature and ensures the client understands, but refers unanswered questions to the surgeon.
Source: NCLEX-RN Test Plan: Management of Care — Informed Consent (provider obtains, RN witnesses)Report a problem with this question
9. A nurse is discussing a client's care in the hallway when a family friend asks about the diagnosis. What is the nurse's best response?
- A.Share the diagnosis since the friend is clearly concerned
- B.Provide general information but omit the client's name
- C.Confirm only whether the client is improving
- D.Decline to share any information without the client's authorization✓ Answer
HIPAA protects a client's health information; it may not be disclosed to anyone without the client's authorization, regardless of the person's relationship or concern.
Source: HIPAA Privacy Rule; NCLEX-RN Test Plan — Confidentiality/Information SecurityReport a problem with this question
10. A nurse is giving a telephone handoff using SBAR. Which information belongs in the 'Recommendation' component?
- A.A request to evaluate the client and consider a stat chest x-ray✓ Answer
- B.The client's name, age, and admitting diagnosis
- C.The current vital signs and lab values
- D.The client's history of hypertension
In SBAR, Recommendation states what the nurse wants done. Name/diagnosis is Situation, current data is Assessment, and history is Background.
Source: NCLEX-RN Test Plan: Management of Care — Handoff/SBAR communicationReport a problem with this question
11. A client is admitted with suspected active pulmonary tuberculosis. Which precautions should the nurse implement?
- A.Droplet precautions with a surgical mask
- B.Standard precautions only
- C.Contact precautions with gown and gloves
- D.Airborne precautions in a negative-pressure room with an N95 respirator✓ Answer
Tuberculosis is transmitted by airborne droplet nuclei, requiring a negative-pressure (AIIR) room and an N95 or higher respirator. A surgical mask does not filter airborne particles.
Source: CDC Transmission-Based Precautions — Airborne (TB, measles, varicella)Report a problem with this question
12. Which client requires the nurse to wear a surgical mask when within 3 feet, but does not require a negative-pressure room?
- A.A client with active tuberculosis
- B.A client with Clostridioides difficile infection
- C.A client with disseminated herpes zoster
- D.A client with Neisseria meningitis✓ Answer
Neisseria meningitis spreads by large respiratory droplets, requiring droplet precautions (surgical mask, private room). TB and disseminated zoster are airborne; C. difficile is contact.
Source: CDC Transmission-Based Precautions — Droplet (Neisseria meningitidis)Report a problem with this question
13. A client has Clostridioides difficile infection. Which hand-hygiene method should the nurse use after care?
- A.Applying gloves without hand hygiene
- B.Soap and water hand washing✓ Answer
- C.Alcohol-based hand rub only
- D.An antiseptic wipe on the hands
C. difficile forms spores that alcohol-based rubs do not kill. Mechanical removal by soap-and-water hand washing (plus contact precautions) is required.
Source: CDC Guideline for Hand Hygiene — spore-forming organisms (C. difficile, norovirus)Report a problem with this question
14. A client is on contact precautions for a MRSA wound infection. Which action is correct?
- A.Wear an N95 respirator when entering the room
- B.Transport the client without any barriers
- C.Don gown and gloves before entering the room✓ Answer
- D.Share the blood pressure cuff with the next client
Contact precautions for MRSA require gown and gloves on room entry and dedicated (not shared) equipment to prevent transmission by direct or indirect contact.
Source: CDC Transmission-Based Precautions — Contact (MRSA, VRE)Report a problem with this question
15. The nurse is putting on personal protective equipment (PPE) to enter an isolation room. What is the correct order?
- A.Gown, mask, goggles, gloves✓ Answer
- B.Goggles, gloves, gown, mask
- C.Mask, gloves, gown, goggles
- D.Gloves, gown, mask, goggles
The correct donning sequence is gown, then mask/respirator, then goggles/face shield, then gloves. Gloves go on last so they cover the gown cuffs.
Source: CDC Sequence for Donning PPEReport a problem with this question
16. When removing PPE after client care, which item should the nurse remove first?
- A.Mask or respirator
- B.Goggles
- C.Gown
- D.Gloves✓ Answer
Gloves are the most contaminated item and are removed first. The mask/respirator is removed last, after leaving the room, to protect the airway until the end.
Source: CDC Sequence for Doffing PPE (gloves first, mask last)Report a problem with this question
17. Which measure is the single most effective way to prevent the spread of infection?
- A.Placing all clients in private rooms
- B.Administering prophylactic antibiotics
- C.Wearing sterile gloves for all care
- D.Performing hand hygiene✓ Answer
Hand hygiene is the single most effective measure to prevent healthcare-associated infection transmission. Gloves supplement but never replace hand hygiene.
Source: CDC/WHO Hand Hygiene Guidelines — most effective infection-control measureReport a problem with this question
18. A client with severe neutropenia is placed on protective (neutropenic) precautions. Which instruction is appropriate?
- A.Place the client in a negative-pressure room
- B.Reuse the client's water pitcher for several days
- C.Remove fresh flowers and fresh raw produce from the room✓ Answer
- D.Allow visitors with respiratory infections
Protective isolation shields the immunocompromised client from external pathogens: use a positive-pressure room and remove fresh flowers and raw produce, which harbor bacteria and fungi.
Source: NCLEX-RN Test Plan: Safety & Infection Control — Protective/Neutropenic isolationReport a problem with this question
19. While preparing a sterile field, which action by the nurse maintains sterility?
- A.Keeping sterile items below waist level for easy reach
- B.Turning away briefly to retrieve a supply
- C.Considering the outer 1-inch border of the field as sterile
- D.Holding sterile objects above the waist and in view✓ Answer
Sterile items must be kept above the waist and within view; anything below the waist or out of sight is considered contaminated. The outer 1-inch border is not sterile, and the nurse never turns her back on the field.
Source: Surgical Asepsis Principles (Potter & Perry) — sterile field maintenanceReport a problem with this question
20. To whom do standard precautions apply?
- A.Only clients with a confirmed infectious diagnosis
- B.Only clients in isolation rooms
- C.Only clients who are immunocompromised
- D.All clients regardless of diagnosis or infection status✓ Answer
Standard precautions are applied to every client at all times, because any client may harbor a bloodborne or other pathogen. Transmission-based precautions are added on top when indicated.
Source: CDC Standard Precautions — apply to all clientsReport a problem with this question
21. A confused client keeps pulling at a necessary IV line. What should the nurse do first?
- A.Administer a PRN sedative to calm the client
- B.Obtain a standing PRN restraint order for future use
- C.Try least-restrictive alternatives such as a family sitter and diversion✓ Answer
- D.Apply wrist restraints immediately
Restraints are a last resort. The nurse must first try least-restrictive alternatives (sitters, diversion, reorientation, camouflaging the line). Restraints are never ordered PRN.
Source: CMS/TJC Restraint Standards — least-restrictive first, no PRN restraintsReport a problem with this question
22. A nurse must apply a wrist restraint after other measures fail and an order is obtained. Which action is correct?
- A.Secure the restraint to the bed frame with a quick-release tie✓ Answer
- B.Leave the restraint in place for 48 hours without reassessment
- C.Tie the restraint to the side rail of the bed
- D.Use a knot that requires scissors to release quickly
Restraints must be tied to the movable bed frame (not the side rail) with a quick-release knot so they don't tighten when the bed moves and can be freed fast in an emergency. Circulation/skin are reassessed q1–2h.
Source: CMS/TJC Restraint Standards — quick-release to bed frame, q1–2h checksReport a problem with this question
23. Which intervention best reduces the risk of falls for an older adult client identified as high-risk?
- A.Keep all four side rails up at all times
- B.Restrain the client to prevent getting out of bed
- C.Place the bed in a low, locked position with the call light in reach✓ Answer
- D.Keep the room dim to encourage rest
A low, locked bed with the call light within reach is a least-restrictive, evidence-based fall precaution. Four raised side rails can be a restraint and increase injury; dim lighting increases fall risk.
Source: NCLEX-RN Test Plan: Safety — Fall Prevention (Morse); National Patient Safety GoalsReport a problem with this question
24. Before administering a medication, the nurse must verify the client's identity. Which method meets the two-identifier standard?
- A.Asking the family member to confirm the client's identity
- B.Verifying the client's name and date of birth against the record✓ Answer
- C.Checking the room number and bed number
- D.Calling the client by name and waiting for a response
Two client identifiers (e.g., name and date of birth) matched to the record/order meet the National Patient Safety Goal. Room/bed number and name alone are not acceptable identifiers.
Source: Joint Commission National Patient Safety Goal 01.01.01 — two identifiersReport a problem with this question
25. A nurse discovers a small fire in a client's trash can. Using the RACE protocol, what is the nurse's first action?
- A.Activate the fire alarm
- B.Confine the fire by closing doors
- C.Extinguish the fire with an extinguisher
- D.Rescue clients in immediate danger✓ Answer
RACE stands for Rescue, Alarm, Confine, Extinguish. The first priority is to rescue anyone in immediate danger from the fire.
Source: Fire Safety Protocol — RACE (Rescue first)Report a problem with this question
26. A client with a seizure disorder is admitted. Which seizure precaution should the nurse implement?
- A.Keep padded side rails up and suction available at the bedside✓ Answer
- B.Keep the client in a well-lit room with bright stimulation
- C.Insert a padded tongue blade into the mouth during a seizure
- D.Restrain the client's limbs during a seizure
Seizure precautions include padded side rails and suction/oxygen at the bedside. During a seizure the nurse never inserts objects in the mouth or restrains limbs; position the client on their side and protect the head.
Source: NCLEX-RN Test Plan: Safety — Seizure PrecautionsReport a problem with this question
27. A client with dysphagia is eating. Which action best reduces the risk of aspiration?
- A.Offer thin liquids to help wash food down
- B.Encourage rapid eating to finish before fatigue
- C.Have the client sit upright at 90 degrees with the chin tucked✓ Answer
- D.Position the client supine while eating
Aspiration precautions require an upright (90°) position with a chin-tuck, which closes the airway during swallowing. Thickened—not thin—liquids are used for dysphagia, and eating should be unhurried.
Source: NCLEX-RN Test Plan: Basic Care & Comfort — Aspiration PrecautionsReport a problem with this question
28. Before administering an intermittent feeding through a nasogastric (NG) tube, what should the nurse do first?
- A.Lay the client flat to prevent reflux
- B.Verify tube placement and check gastric residual✓ Answer
- C.Flush the tube with 60 mL of sterile water
- D.Warm the formula in a microwave
The nurse must confirm correct tube placement and check gastric residual before feeding to prevent instilling formula into a displaced tube and to detect delayed emptying. The head of the bed is elevated, not flat.
Source: NCLEX-RN Test Plan: Basic Care & Comfort — Enteral Nutrition/Tube feedingReport a problem with this question
29. A client with left-sided weakness is learning to use a cane. On which side should the nurse instruct the client to hold the cane?
- A.On the right (strong) side✓ Answer
- B.Alternating sides with each step
- C.In whichever hand feels comfortable
- D.On the left (weak) side
The cane is held on the strong (unaffected) side to widen the base of support and shift weight away from the weak leg. The cane and weak leg advance together.
Source: Body Mechanics/Assistive Devices (Potter & Perry) — cane on strong sideReport a problem with this question
30. A client using crutches is learning to climb stairs. Which instruction is correct?
- A.Lead with the weak leg going up the stairs
- B.Descend stairs leading with the strong leg
- C.Lead with the strong leg going up the stairs✓ Answer
- D.Place both crutches on the higher step first
The rule is 'up with the good, down with the bad': the strong leg leads going up, and the weak leg (with crutches) leads going down. This keeps the stronger limb bearing weight on the step.
Source: Crutch Gait Teaching — 'up with the good, down with the bad'Report a problem with this question
31. Which nursing action is most important for preventing pressure injuries in an immobile client?
- A.Massaging reddened bony prominences vigorously
- B.Using a doughnut-shaped ring cushion under the sacrum
- C.Keeping the head of the bed elevated above 45 degrees continuously
- D.Repositioning the client at least every 2 hours✓ Answer
Repositioning at least every 2 hours relieves capillary pressure and is the cornerstone of prevention. Massaging reddened areas and doughnut cushions cause more tissue damage, and continuous high HOB increases sacral shear.
Source: NPIAP Pressure Injury Prevention Guidelines — reposition q2hReport a problem with this question
32. A nurse assesses a pressure injury with intact skin and a localized area of nonblanchable erythema. How should the nurse stage it?
- A.Stage 4
- B.Stage 1✓ Answer
- C.Stage 2
- D.Stage 3
Stage 1 is intact skin with nonblanchable erythema. Stage 2 involves partial-thickness loss with exposed dermis; Stage 3 exposes fat; Stage 4 exposes muscle, tendon, or bone.
Source: NPIAP Pressure Injury Staging System — Stage 1Report a problem with this question
33. A client with heart failure is placed on a therapeutic diet. Which meal choice best reflects appropriate teaching?
- A.Canned soup with crackers and processed cheese
- B.A cured ham sandwich with a dill pickle
- C.Grilled fresh chicken with steamed vegetables and rice✓ Answer
- D.Instant noodles with soy sauce
Heart failure requires a low-sodium diet. Fresh chicken with steamed vegetables is low in sodium; canned soup, cured ham/pickles, and instant noodles/soy sauce are all high-sodium and promote fluid retention.
Source: NCLEX-RN Test Plan: Basic Care & Comfort — Therapeutic (low-sodium) dietReport a problem with this question
34. The nurse is preparing to administer a cleansing enema. In which position should the client be placed?
- A.Left lateral (Sims) position✓ Answer
- B.High Fowler's position
- C.Right lateral (Sims) position
- D.Prone position
The left lateral (Sims) position follows the natural curve of the sigmoid colon and descending colon, allowing the solution to flow by gravity and be retained more effectively.
Source: NCLEX-RN Test Plan: Basic Care & Comfort — Elimination/Enema techniqueReport a problem with this question
35. Which method is most accurate for confirming placement of a newly inserted NG tube before first use?
- A.Auscultating air injected into the tube
- B.X-ray confirmation of tube tip placement✓ Answer
- C.Placing the tube's end in water to check for bubbling
- D.Observing for the absence of coughing
Radiographic confirmation is the gold standard for verifying NG tube tip placement before first use. The air-auscultation ('whoosh') test is unreliable and no longer recommended.
Source: AACN/current standards — X-ray confirmation of NG tube placementReport a problem with this question
36. A nurse is measuring orthostatic (postural) blood pressures. Which technique is correct?
- A.Take supine, then sitting/standing readings after position changes✓ Answer
- B.Measure BP only while the client is standing
- C.Have the client stand up quickly and measure immediately
- D.Measure BP in the same position three times in a row
Orthostatic vitals are measured supine, then after the client sits and/or stands (waiting ~1–3 minutes each). A drop of ≥20 mmHg systolic or ≥10 mmHg diastolic indicates orthostatic hypotension and fall risk.
Source: NCLEX-RN Test Plan: Reduction of Risk — Vital sign technique (orthostatic)Report a problem with this question
37. A nurse reviews morning labs. Which potassium result should be reported to the provider immediately?
- A.Potassium 4.5 mEq/L
- B.Potassium 2.8 mEq/L✓ Answer
- C.Potassium 4.0 mEq/L
- D.Potassium 3.8 mEq/L
Normal potassium is 3.5–5.0 mEq/L. A value of 2.8 mEq/L is critically low (hypokalemia) and can cause life-threatening dysrhythmias, so it must be reported immediately. The other values are within normal range.
Source: Standard lab reference — serum potassium 3.5–5.0 mEq/LReport a problem with this question
38. A nurse is monitoring a post-operative client. Which set of findings most indicates the client is deteriorating and needs immediate action?
- A.BP 132/84, HR 72, RR 14, resting comfortably
- B.BP 86/50, HR 124, RR 28, increasing confusion✓ Answer
- C.BP 118/76, HR 78, RR 16, alert
- D.BP 128/80, HR 88, RR 18, mild incisional pain
Falling BP, rising heart and respiratory rates, and new confusion signal shock and inadequate perfusion—a deteriorating client requiring immediate intervention and provider notification.
Source: NCLEX-RN Test Plan: Reduction of Risk — recognizing the deteriorating clientReport a problem with this question
39. A client receiving a blood transfusion suddenly reports chills, flank pain, and fever. What is the nurse's first action?
- A.Notify the provider before stopping the transfusion
- B.Stop the transfusion immediately and keep the line open with normal saline✓ Answer
- C.Slow the transfusion and continue monitoring
- D.Administer an antipyretic and reassess in 30 minutes
Chills, flank pain, and fever suggest an acute hemolytic transfusion reaction. The nurse's first action is to stop the transfusion immediately and keep the IV line open with normal saline, then notify the provider and blood bank.
Source: NCLEX-RN Test Plan: Pharmacological Therapies — Transfusion reaction (stop, keep line open with NS)Report a problem with this question
40. A nurse notes that a peripheral IV site is cool, pale, and swollen, and the infusion has slowed. What does this most likely indicate?
- A.Phlebitis
- B.Air embolism
- C.Systemic allergic reaction
- D.Infiltration✓ Answer
Coolness, pallor, swelling, and a slowed infusion indicate infiltration—IV fluid leaking into surrounding tissue. The nurse stops the infusion and removes the catheter. Phlebitis presents with warmth, redness, and tenderness.
Source: NCLEX-RN Test Plan: Pharmacological Therapies — IV complications (infiltration)Report a problem with this question
41. According to Erikson, a hospitalized toddler is in which stage of psychosocial development?
- A.Initiative vs. guilt
- B.Industry vs. inferiority
- C.Trust vs. mistrust
- D.Autonomy vs. shame and doubt✓ Answer
Toddlers (roughly 1–3 years) are in Erikson's autonomy vs. shame and doubt stage. Care should support independence (e.g., choices), whereas infants are in trust vs. mistrust and preschoolers in initiative vs. guilt.
Source: Erikson's Stages of Psychosocial Development — toddler (autonomy vs. shame/doubt)Report a problem with this question
42. A nurse is teaching new parents about safe sleep to reduce the risk of sudden infant death syndrome (SIDS). Which instruction is correct?
- A.Place the infant to sleep on the stomach
- B.Place the infant to sleep on the back on a firm surface✓ Answer
- C.Have the infant sleep in the parents' bed
- D.Use soft pillows and bumper pads in the crib
The 'Back to Sleep' recommendation places infants supine on a firm, bare sleep surface to reduce SIDS risk. Prone/side positions, soft bedding, bumpers, and bed-sharing all increase risk.
Source: AAP Safe Sleep Guidelines — supine ('Back to Sleep')Report a problem with this question
43. A community health nurse organizes a mammography screening event. This is an example of which level of prevention?
- A.Tertiary prevention
- B.Secondary prevention✓ Answer
- C.Primary prevention
- D.Quaternary prevention
Secondary prevention aims to detect disease early through screening (e.g., mammography, Pap smear). Primary prevention prevents disease before it occurs (e.g., immunization), and tertiary prevention manages established disease.
Source: NCLEX-RN Test Plan: Health Promotion — levels of prevention (secondary = screening)Report a problem with this question
44. A client newly diagnosed with cancer says, 'I just don't know how I'll get through this.' Which response by the nurse is most therapeutic?
- A.'Why are you so upset? Many people beat cancer.'
- B.'You sound frightened. Tell me more about what you're feeling.'✓ Answer
- C.'Don't worry, everything will be fine.'
- D.'Let's talk about something more positive.'
Reflecting the client's feeling and using an open-ended invitation encourages expression and shows empathy. False reassurance, 'why' questions, and changing the subject all block therapeutic communication.
Source: NCLEX-RN Test Plan: Psychosocial Integrity — Therapeutic CommunicationReport a problem with this question
45. A client scheduled for a mastectomy states, 'There's no point in the surgery.' Which nursing response is most appropriate?
- A.'You shouldn't feel that way before surgery.'
- B.'Of course it has a point—it could save your life.'
- C.'Tell me more about what's making you feel this way.'✓ Answer
- D.'I'll let the surgeon know you refuse the operation.'
An open-ended, exploring response invites the client to express feelings and lets the nurse assess concerns. Disagreeing, giving disapproval, or prematurely acting on the statement shuts down communication.
Source: NCLEX-RN Test Plan: Psychosocial Integrity — Therapeutic Communication (exploring)Report a problem with this question
46. A client on a psychiatric unit expresses a specific plan to harm themselves. What is the nurse's priority?
- A.Explore the underlying reasons for the client's feelings
- B.Notify the family of the client's statements
- C.Document the statement in the chart and continue rounds
- D.Ensure client safety with close observation and remove hazards✓ Answer
When a client expresses a specific self-harm plan, safety is always the priority: institute close/1:1 observation and remove hazardous objects. Exploring feelings and documentation follow after safety is secured.
Source: NCLEX-RN Test Plan: Psychosocial Integrity — suicide risk (safety priority)Report a problem with this question
47. A client whose spouse died recently says angrily, 'The doctors should have done more!' Which stage of grief (Kübler-Ross) does this reflect?
- A.Acceptance
- B.Bargaining
- C.Anger✓ Answer
- D.Denial
Blaming others and expressing outrage reflect the anger stage of Kübler-Ross's grief model. The nurse should allow expression of anger without taking it personally, rather than becoming defensive.
Source: Kübler-Ross Five Stages of Grief — angerReport a problem with this question
48. An arterial blood gas shows pH 7.30, PaCO2 55 mmHg, HCO3 24 mEq/L. How should the nurse interpret this?
- A.Respiratory alkalosis
- B.Metabolic alkalosis
- C.Metabolic acidosis
- D.Respiratory acidosis✓ Answer
pH 7.30 is acidic and PaCO2 55 is elevated (normal 35–45), so the acidosis is respiratory in origin. HCO3 is normal (22–26), indicating no metabolic compensation yet. Using ROME: Respiratory Opposite—pH down, CO2 up.
Source: ABG interpretation (ROME) — respiratory acidosisReport a problem with this question
49. A client with hypokalemia is receiving diuretic therapy. Which food should the nurse encourage to help raise potassium?
- A.White bread
- B.Butter
- C.Bananas and potatoes✓ Answer
- D.Egg whites
Bananas and potatoes are high in potassium and help correct hypokalemia caused by potassium-wasting diuretics. White bread, egg whites, and butter are poor potassium sources.
Source: NCLEX-RN Test Plan: Physiological Adaptation — electrolyte (potassium-rich foods)Report a problem with this question
50. A nurse finds an unresponsive adult client who is not breathing and has no pulse. After calling for help, what should the nurse do next?
- A.Place the client in the recovery position
- B.Check the blood glucose level
- C.Give two rescue breaths first
- D.Begin high-quality chest compressions✓ Answer
Current BLS uses the C-A-B sequence: after confirming no pulse and calling for help, begin chest compressions immediately to restore circulation, before airway and breathing.
Source: AHA Basic Life Support — C-A-B sequence (compressions first)Report a problem with this question
51. A nurse makes a medication error but the client is unharmed. What is the nurse's appropriate action?
- A.Ask a coworker to change the record to hide the error
- B.Assess the client, notify the provider, and complete an incident report✓ Answer
- C.Wait to see if any symptoms develop before reporting
- D.Omit documentation since no harm occurred
After any error, the nurse first assesses the client's safety, notifies the provider, and completes an incident/occurrence report. Errors and near-misses are reported honestly to improve system safety, never concealed.
Source: NCLEX-RN Test Plan: Safety — error/near-miss reporting; incident reportsReport a problem with this question
Practice questions based on the NCSBN NCLEX-RN test plan. Not affiliated with NCSBN and not medical advice — always follow your program and current clinical guidelines. About the NCLEX →