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NCLEX Exam
NCLEX Practice Exam for Foundation of Nursing

NCLEX Practice Exam for

Foundation of Nursing
PRACTICE MODE
EXAM MODE
TEXT MODE

Text Mode – Text version of the exam

1. The most important nursing intervention to correct skin dryness is:

A. Avoid bathing the patient until the condition is remedied, and notify the
physician
B. Ask the physician to refer the patient to a dermatologist, and suggest that
the patient wear home-laundered sleepwear
C. Consult the dietitian about increasing the patient’s fat intake, and take
necessary measures to prevent infection
 D. Encourage the patient to increase his fluid intake, use nonirritating soap
when bathing the patient, and apply lotion to the involved areas
2. When bathing a patient’s extremities, the nurse should use long, firm
strokes from the distal to the proximal areas. This technique:

A. Provides an opportunity for skin assessment

B. Avoids undue strain on the nurse
C. Increases venous blood return
D. Causes vasoconstriction and increases circulation
3. Vivid dreaming occurs in which stage of sleep?

A. Stage I non-REM
B. Rapid eye movement (REM) stage
C. Stage II non-REM
D. Delta stage
4. The natural sedative in meat and milk products (especially warm milk) that
can help induce sleep is:

A. Flurazepam
B. Temazepam
C. Tryptophan
D. Methotrimeprazine
5. Nursing interventions that can help the patient to relax and sleep restfully
include all of the following except:

A. Have the patient take a 30- to 60-minute nap in the afternoon

B. Turn on the television in the patient’s room
C. Provide quiet music and interesting reading material
D. Massage the patient’s back with long strokes
6. Restraints can be used for all of the following purposes except to:

A. Prevent a confused patient from removing tubes, such as feeding tubes,

I.V. lines, and urinary catheters
B. Prevent a patient from falling out of bed or a chair
C. Discourage a patient from attempting to ambulate alone when he requires
assistance for his safety
D. Prevent a patient from becoming confused or disoriented
7. Which of the following is the nurse’s legal responsibility when applying
restraints?

A. Document the patient’s behavior

 B. Document the type of restraint used
C. Obtain a written order from the physician except in an emergency, when
the patient must be protected from injury to himself or others
D. All of the above
8. Kubler-Ross’s five successive stages of death and dying are:

A. Anger, bargaining, denial, depression, acceptance

B. Denial, anger, depression, bargaining, acceptance
C. Denial, anger, bargaining, depression acceptance
D. Bargaining, denial, anger, depression, acceptance
9. A terminally ill patient usually experiences all of the following feelings during
the anger stage except:

A. Rage
B. Envy
C. Numbness
D. Resentment
10. Nurses and other health care provides often have difficulty helping a
terminally ill patient through the necessary stages leading to acceptance of
death. Which of the following strategies is most helpful to the nurse in
achieving this goal?

A. Taking psychology courses related to gerontology

B. Reading books and other literature on the subject of thanatology
C. Reflecting on the significance of death
D. Reviewing varying cultural beliefs and practices related to death
11. Which of the following symptoms is the best indicator of imminent death?

A. A weak, slow pulse

B. Increased muscle tone
C. Fixed, dilated pupils
D. Slow, shallow respirations
12. A nurse caring for a patient with an infectious disease who requires
isolation should refers to guidelines published by the:

A. National League for Nursing (NLN)

B. Centers for Disease Control (CDC)
C. American Medical Association (AMA)
D. American Nurses Association (ANA)
13. To institute appropriate isolation precautions, the nurse must first know
the:
 A. Organism’s mode of transmission
B. Organism’s Gram-staining characteristics
C. Organism’s susceptibility to antibiotics
D. Patient’s susceptibility to the organism
14. Which is the correct procedure for collecting a sputum specimen for
culture and sensitivity testing?

A. Have the patient place the specimen in a container and enclose the
container in a plastic bag
B. Have the patient expectorate the sputum while the nurse holds the
container
C. Have the patient expectorate the sputum into a sterile container
D. Offer the patient an antiseptic mouthwash just before he expectorate the
sputum
15. An autoclave is used to sterilize hospital supplies because:

A. More articles can be sterilized at a time

B. Steam causes less damage to the materials
C. A lower temperature can be obtained
D. Pressurized steam penetrates the supplies better
16. The best way to decrease the risk of transferring pathogens to a patient
when removing contaminated gloves is to:

A. Wash the gloves before removing them

B. Gently pull on the fingers of the gloves when removing them
C. Gently pull just below the cuff and invert the gloves when removing them
D. Remove the gloves and then turn them inside out
17. After having an I.V. line in place for 72 hours, a patient complains of
tenderness, burning, and swelling. Assessment of the I.V. site reveals that it is
warm and erythematons. This usually indicates:

A. Infection
B. Infiltration
C. Phlebitis
D. Bleeding
18. To ensure homogenization when diluting powdered medication in a vial,
the nurse should:

A. Shake the vial vigorously

B. Roll the vial gently between the palms
C. Invert the vial and let it stand for 1 minute
 D. Do nothing after adding the solution to the vial
19. The nurse is teaching a patient to prepare a syringe with 40 units of U-100
NPH insulin for self-injection. The patient’s first priority concerning self-
injection in this situation is to:

A. Assess the injection site

B. Select the appropriate injection site
C. Check the syringe to verify that the nurse has removed the prescribed
insulin dose
D. Clean the injection site in a circular manner with and alcohol sponge
20. The physician’s order reads “Administer 1 g cefazolin sodium (Ancef) in
150 ml of normal saline solution in 60 minutes.” What is the flow rate if the
drop factor is 10 gtt = 1 ml?

A. 25 gtt/minute
B. 37 gtt/minute
C. 50 gtt/minute
D. 60 gtt/minute
21. A patient must receive 50 units of Humulin regular insulin. The label reads
100 units = 1 ml. How many milliliters should the nurse administer?

A. 0.5 ml
B. 0.75 ml
C. 1 ml
D. 2 ml
22. How should the nurse prepare an injection for a patient who takes both
regular and NPH insulin?

A. Draw up the NPH insulin, then the regular insulin, in the same syringe
B. Draw up the regular insulin, then the NPH insulin, in the same syringe
C. Use two separate syringe
D. Check with the physician
23. A patient has just received 30 mg of codeine by mouth for pain. Five
minutes later he vomits. What should the nurse do first?

A. Call the physician

B. Remedicate the patient
C. Observe the emesis
D. Explain to the patient that she can do nothing to help him
24. A patient is characterized with a #16 indwelling urinary (Foley) catheter to
determine if:
 A. Trauma has occurred
B. His 24-hour output is adequate
C. He has a urinary tract infection
D. Residual urine remains in the bladder after voiding
25. A staff nurse who is promoted to assistant nurse manager may feel
uncomfortable initially when supervising her former peers. She can best
decrease this discomfort by:

A. Writing down all assignments

B. Making changes after evaluating the situation and having discussions with
the staff.
C. Telling the staff nurses that she is making changes to benefit their
performance
D. Evaluating the clinical performance of each staff nurse in a private
conference
Answers and Rationales
1. Answer – D. Dry skin will eventually crack, ranking the patient more prone
to infection. To prevent this, the nurse should provide adequate hydration
through fluid intake, use nonirritating soaps or no soap when bathing the
patient, and lubricate the patient’s skin with lotion. Bathing may be limited
but need not be avoided entirely. The attending physician and dietitian
may be consulted for treatment, but home-laundered items usually are not
necessary.

2. Answer – C. Washing from distal to proximal areas stimulates venous

blood flow, thereby preventing venous stasis. It improves circulation but
does not result in vasoconstriction. The nurse can assess the patient’s
condition throughout the bath, regardless of washing technique, and
should feel no strain while bathing the patient.

3. Answer – B. Other characteristics of rapid eye movement (REM) sleep are

deep sleep (the patient cannot be awakened easily), depressed muscle
tone, and possibly irregular heart and respiratory rates. Non-REM sleep is
a deep, restful sleep without dreaming. Delta stage, or slow-wave sleep,
occurs during non-REM Stages III and IV and is often equated with quiet
sleep.

4. Answer – C. Tryptophan is a natural sedative; flurazepam (Dalmane),

temazepam (Restoril), and methotrimeprazine (Levoprome) are hypnotic
 sedatives.

5. Answer – A. Napping in the afternoon is not conductive to nighttime

sleeping. Quiet music, watching television, reading, and massage usually
will relax the patient, helping him to fall asleep.

6. Answer – D. By restricting a patient’s movements, restraints may increase

stress and lead to confusion, rather than prevent it. The other choices are
valid reasons for using restraints.

7. Answer – D. When applying restraints, the nurse must document the type
of behavior that prompted her to use them, document the type of restraints
used, and obtain a physician’s written order for the restraints.

8. Answer – C. Kubler-Ross’s five successive stages of death and dying are

denial, anger, bargaining, depression, and acceptance. The patient may
move back and forth through the different stages as he and his family
members react to the process of dying, but he usually goes through all of
these stages to reach acceptance.

9. Answer – C. Numbness is typical of the depression stage, when the patient

feels a great sense of loss. The anger stage includes such feelings as
rage, envy, resentment, and the patient’s questioning “Why me?”

10. Answer – C. According to thanatologists, reflecting on the significance of

death helps to reduce the fear of death and enables the health care
provider to better understand the terminally ill patient’s feelings. It also
helps to overcome the belief that medical and nursing measures have
failed, when a patient cannot be cured.

11. Answer – C. Fixed, dilated pupils are sign of imminent death. Pulse
becomes weak but rapid, muscles become weak and atonic, and periods
of apnea occur during respiration.

12. Answer – B. The Center of Disease Control (CDC) publishes and

frequently updates guidelines on caring for patients who require isolation.
The National League of Nursing’s (NLN’s) major function is accrediting
nursing education programs in the
United States. The American Medical Association (AMA) is a national
organization of physicians. The American Nurses’ Association (ANA) is a
 national organization of registered nurses.

13. Answer – A. Before instituting isolation precaution, the nurse must first
determine the organism’s mode of transmission. For example, an
organism transmitted through nasal secretions requires that the patient be
kept in respiratory isolation, which involves keeping the patient in a private
room with the door closed and wearing a mask, a grown, and gloves when
coming in direct contact with the patient. The organism’s Gram-straining
characteristics reveal whether the organism is gram-negative or gram-
positive, an important criterion in the physician’s choice for drug therapy
and the nurse’s development of an effective plan of care. The nurse also
needs to know whether the organism is susceptible to antibiotics, but this
could take several days to determine; if she waits for the results before
instituting isolation precautions, the organism could be transmitted in the
meantime. The patient’s susceptibility to the organism has already been
established. The nurse would not be instituting isolation precautions for a
noninfected patient.

14. Answer – C. Placing the specimen in a sterile container ensures that it

will not become contaminated. The other answers are incorrect because
they do not mention sterility and because antiseptic mouthwash could
destroy the organism to be cultured (before sputum collection, the patient
may use only tap water for nursing the mouth).

15. Answer – D. An autoclave, an apparatus that sterilizes equipment by

means of high-temperature pressured steam, is used because it can
destroy all forms of microorganisms, including spores.

16. Answer – C. Turning the gloves inside out while removing them keeps all
contaminants inside the gloves. They should than be placed in a plastic
bag with soiled dressings and discarded in a soiled utility room garbage
pail (double bagged). The other choices can spread pathogens within the
environment.

17. Answer – C. Tenderness, warmth, swelling, and, in some instances, a

burning sensation are signs and symptoms of phlebitis. Infection is less
likely because no drainage or fever is present. Infiltration would result in
swelling and pallor, not erythema, near the insertion site. The patient has
no evidence of bleeding.
18. Answer – B. Gently rolling a sealed vial between the palms produces
sufficient heat to enhance dissolution of a powdered medication. Shaking
the vial vigorously can break down the medication and alter its
pharmacologic action. Inverting the vial or leaving it alone does not ensure
thorough homogenization of the powder and the solvent.

19. Answer – C. When the nurse teaches the patient to prepare an insulin
injection, the patient’s first priority is to validate the dose accuracy. The
next steps are to select the site, assess the site, and clean the site with
alcohol before injecting the insulin.

20. Answer – A. 25 gtt/minute

21. Answer – A. 0.5 ml

22. Answer – B. Drugs that are compatible may be mixed together in one
syringe. In the case of insulin, the shorter-acting, clear insulin (regular)
should be drawn up before the longer-acting, cloudy insulin (NPH) to
ensure accurate measurements.

23. Answer – C. After a patient has vomited, the nurse must inspect the
emesis to document color, consistency, and amount. In this situation, the
patient recently ingested medication, so the nurse needs to check for
remnants of the medication to help determine whether the patient retained
enough of it to be effective. The nurse must then notify the physician, who
will decide whether to repeat the dose or prescribe an antiemetic.

24. Answer – B. A 24-hour urine output of less than 500 ml in an adult is

considered inadequate and may indicate kidney failure. This must be
corrected while the patient is in the acute state so that appropriate fluids,
electrolytes, and medications can be administered and excreted.
Indwelling catheterization is not needed to diagnose trauma, urinary tract
infection, or residual urine.

25. Answer – B. A new assistant nurse manger should not make changes
until she has had a chance to evaluate staff members, patients, and
physicians. Changes must be planned thoroughly and should be based on
a need to improve conditions, not just for the sake of change. Written
assignments allow all staff members to know their own and others
responsibilities and serve as a checklist for the manager, enabling her to
 gauge whether the unit is being run effectively and whether patients are
receiving appropriate care. Telling the staff nurses that she is making
changes to benefit their performance should occur only after the nurse has
made a thorough evaluation. Evaluations are usually done on a yearly
basis or as needed.

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