Nursing Fundamentals Final Exam - NCLEX Style

Nursing Fundamentals Final Exam - NCLEX Style Questions - 2025 Leave the first rating Students also studied Terms in this set (96) Science MedicineNursing Save Nursing Fundamentals Final Exam 216 terms bianca14Preview Fundamentals of Nursing Final Exa...342 terms jrbraatenPreview Nursing Fundamentals Final Exam St...123 terms nmill190Preview Fundam 134 term Abi What should a nurse do if a patient reports they cannot breathe while lying flat?Assess for orthopnea, elevate the head of the bed, and check oxygen saturation levels.Which intervention should a nurse prioritize for a patient with a new onset of confusion and slurred speech?Assess vital signs, check blood glucose levels, and perform a neurological assessment.A nurse is assessing a patient who reports severe pain after surgery. What is the priority action?Assess pain using a pain scale, check vital signs, and administer prescribed pain medication.What is the nurse's priority when a patient is experiencing a seizure?Maintain airway patency, turn the patient onto their side, and time the seizure duration.A patient is admitted with dehydration and reports feeling dizzy upon standing. What intervention should the nurse implement first?Assess orthostatic blood pressure and pulse, then encourage fluid intake as tolerated.A nurse is preparing to administer IV contrast dye for a CT scan. What assessment is necessary before proceeding?Check for iodine or shellfish allergies and assess kidney function (BUN, creatinine).A patient is experiencing difficulty swallowing following a stroke. What is the nurse's priority action?Keep the patient NPO until a swallow evaluation is completed by speech therapy.Which vital sign change would be most concerning in a patient receiving opioids?A respiratory rate of 8 breaths per minute.

A nurse enters a room and notices a patient has a flushed face, dry skin, and a temperature of 103°F (39.4°C). What is the priority action?Initiate cooling measures such as removing excess clothing, providing cool fluids, and applying cold packs.A patient with COPD has an oxygen saturation of 88%.What should the nurse do next?Assess the patient's respiratory effort and confirm if this is their baseline saturation.A nurse is educating a patient with diabetes about foot care. Which statement by the patient indicates understanding?"I will inspect my feet daily and avoid walking barefoot." A patient is admitted with a potassium level of 6.2 mEq/L.What is the most serious potential complication?Cardiac dysrhythmias.A nurse is caring for a patient with C. difficile. What personal protective equipment (PPE) is required?Gown and gloves.What should a nurse do first if a patient begins choking while eating?Encourage the patient to cough forcefully. If ineffective, perform the Heimlich maneuver.Which statement by a nurse to a patient in palliative care demonstrates an understanding of end-of-life care?"We will focus on keeping you comfortable and managing any symptoms you may have." What is the priority intervention for a patient experiencing delirium?Identify and treat the underlying cause, such as infection or medication side effects.A patient with dementia becomes agitated during morning care. What should the nurse do?Use a calm voice, provide reassurance, and attempt care at a later time.A nurse is preparing to delegate a task to an unlicensed assistive personnel (UAP). Which task is appropriate to delegate?Obtaining a routine blood pressure reading.A patient with suspected pneumonia has labored breathing and a respiratory rate of 32. What action should the nurse take first?Administer supplemental oxygen as prescribed and assess lung sounds.A nurse is assessing a patient's pain. Which question is best to determine pain intensity?"On a scale of 0 to 10, how would you rate your pain?" A patient has been prescribed metformin. What is the most important pre-procedure assessment before a CT scan with contrast?Check renal function to prevent contrast-induced nephropathy.A patient with hypertension is prescribed a diuretic. What patient teaching is most important?"Change positions slowly to prevent dizziness and falls." A patient is receiving a blood transfusion and reports itching and difficulty breathing. What is the nurse's first action?Stop the transfusion immediately.

A nurse is performing hand hygiene before patient care.What is the minimum amount of time to wash hands?At least 20 seconds.A patient with heart failure is on a fluid restriction. Which statement by the patient requires further teaching?"I can drink as much water as I want as long as I don't feel thirsty." A nurse is caring for a patient who is Muslim. Which dietary restriction should be considered?Avoiding pork and alcohol.What is the best way to ensure a patient understands discharge instructions?Ask the patient to repeat the instructions in their own words.A nurse is reviewing a patient's chart and notices the documentation states, "Patient states pain is a 7 out of 10." What type of data is this?Subjective data.A nurse is assessing a postoperative patient and notices absent bowel sounds. What is the most appropriate action?Continue to monitor and assess for signs of paralytic ileus.What is the nurse's best response when a patient asks why they need to ambulate after surgery?"Walking helps prevent blood clots and promotes healing." Which task should a nurse avoid delegating to a UAP? Assessing a patient's pain level.What is the best position for a patient receiving an enteral tube feeding?Semi-Fowler's position (30-45 degrees).A patient with osteoporosis asks how to reduce the risk of fractures. What should the nurse recommend?"Increase calcium and vitamin D intake and engage in weight-bearing exercises." What is the priority intervention for a patient experiencing anaphylaxis?Administer epinephrine immediately.A patient with heart failure reports sudden weight gain of

• lbs in three days. What should the nurse do?

Assess for signs of fluid overload and notify the healthcare provider.What should a nurse do when a patient receiving IV therapy develops redness, warmth, and swelling at the IV site?Discontinue the IV and initiate a new site.A nurse is preparing to administer an IM injection. What is the preferred site for an adult?Ventrogluteal muscle.A nurse is performing a head-to-toe assessment on a newly admitted patient. When should this assessment be completed?As soon as the patient is admitted.Which intervention is most important for preventing falls in hospitalized patients?Ensuring the call light is within reach and the bed is in the lowest position.

What is the priority action for a patient experiencing hypoglycemia?Give the patient a source of fast-acting glucose, such as juice or glucose tablets.What action should a nurse take when documenting an error in a paper medical record?Draw a single line through the error, write "error," and initial it.What is the most important consideration when applying restraints?Use the least restrictive method and reassess frequently.Which statement indicates a patient with heart failure understands dietary recommendations?"I will limit my sodium intake to help manage fluid retention." What is the nurse's best action when a patient refuses medication?Document the refusal and notify the healthcare provider if necessary.A patient with low health literacy is being discharged with new medications. What is the best approach for teaching?Use simple language, written instructions, and teach-back methods.What should a nurse assess before an Intravenous Pyelogram (IVP)?Assess for iodine, shellfish, or contrast dye allergies; keep the patient NPO for 8 hours before the test.A patient is scheduled for a CT scan with contrast. What nursing considerations should be addressed?Assess for iodine/shellfish allergies, check kidney function (BUN, creatinine, eGFR), withhold metformin on test day and for 2 days after, and encourage fluids post-procedure.A patient with a pacemaker is scheduled for an MRI. What should the nurse do?Notify the provider, as MRIs are contraindicated in patients with ferrous metal implants.What is the priority nursing assessment after an arteriography?Monitor for bleeding, hematoma, and vascular complications at the catheter insertion site.A patient is scheduled for a CTA scan but has kidney disease. What should the nurse anticipate?The test may be performed without contrast due to the risk of nephrotoxicity.Which diagnostic tests do NOT use contrast medium? Chest X-ray, KUB X-ray, MRI without contrast, ultrasound, ECG.How should a nurse assess a patient's respiratory rate without the patient being aware?Place the patient's arm across their chest or abdomen, hold the pulse site, and count respirations while pretending to assess the pulse.What is the normal respiratory rate for an adult? 12-20 breaths per minute.What is tachypnea?A respiratory rate above 20 breaths per minute.What is apnea?Absence of respirations for a prolonged period.What is dyspnea?Labored or difficult breathing.What is orthopnea?Difficulty breathing unless in an upright position.