NCLEX-RN FUNDAMENTALS EXAM 2024
EXAM 2024-2025 WITH ACTUAL
CORRECT QUESTIONS AND VERIFIED
DETAILED ANSWERS |FREQUENTLY
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The nurse is caring for patients on the medical-surgical unit. The nurse receives an order for hydrocolloid
dressings to be used for pressure ulcers on the patient's elbow and scapula. The nurse knows the
purpose of using a hydrocolloid dressing is what?
a. Hydrocolloid dressings provide an antibiotic solution for killing surface bacteria, thus promoting
healing.
b. Hydrocolloid dressings protect wound bases and maintain a moist environment.
c. Hydrocolloid dressings can be changed frequently and not cause damage to the wound bed.
d. Hydrocolloid dressings perform debriding for a clean wound environment.
b. Hydrocolloid dressings protect wound bases and maintain a moist environment.
Hydrocolloid dressings are used to maintain a moist environment to protect the wound base and
support the growth of new tissue.
A is incorrect because hydrocolloid dressings do not provide antibiotics.
C is incorrect because hydrocolloid dressings require changing only every 3-5 days.
The nurse is assessing patients on the medical-surgical unit for pressure ulcer risk. Which of the
following patients is at greatest risk?
a. 75-year-old patient with Alzheimer's and poor oral intake.
b. 48-year-old patient with paraplegia in a wheelchair.
c. 56-year-old patient with type 1 diabetes who is post-op day one cardiac surgery and has been
diaphoretic
d. 65-year-old patient who had bladder surgery and is incontinent.
c. 56-year-old patient with type 1 diabetes who is post-op day one cardiac surgery and has been
diaphoretic
This patient has three risk factors for development of a pressure ulcer: type 1 diabetes (impairing
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,vasculature and sensation), limited mobility due to surgery, and diaphoresis (leaving the skin moist
and at greater risk for tearing).
The nurse is caring for a patient who has developed severe conjunctivitis. The patient wears contact
lenses. When the nurse educates the patient regarding prevention of recurrent conjunctivitis, which
statement by the patient indicates a knowledge deficit?
a. "Any open contact lens solutions should be discarded once I get home."
b. "Any solution that is cloudy should be discarded."
c. "Household hand soap for handwashing is sufficient before handling contact lenses."
d. "I'll be requesting disposable contacts so there's no risk for infection."
d. "I'll be requesting disposable contacts so there's no risk for infection."
All types of contact lenses carry a risk of becoming contaminated and causing conjunctivitis. Some
contact lenses are reusable, requiring a proper washing in-between insertion. The patient should be
taught the importance of proper handwashing when handling the contact lenses, and the importance
of following all manufacturer's guidelines pertaining to the insertion and care of the contact lenses.
Conjunctivitis (aka "pinkeye") is conjunctiva inflammation. It is characterized by pink color to the
sclera of the eye, due to conjunctival blood vessel hemorrhage. General symptoms include: a feeling
of a foreign body in the eye, scratching or burning sensation, photophobia, and exudate from the eye.
It can be unilateral or bilateral. The most common causes of bacterial conjunctivitis are Strep.
pneumoniae, H. influenza, and Staph. aureus.
A patient who wears bilateral hearing aids tells the nurse they have discomfort in the right ear. What is
the first intervention the nurse should perform?
a. Ask the patient if they understand hearing aid care.
b. Assess the ears for inflammation.
c. Teach the patient how to reposition the hearing aids to decrease discomfort.
d. Turn down the volume of the left hearing aid.
b. Assess the ears for inflammation.
The ears must be assessed by the nurse before any interventions are performed. Any irritation,
inflammation, or infection must be identified. What is found during assessment determines the most
appropriate intervention.
A patient in the clinic tells the nurse they are experiencing increasing pain in the right ear. What initial
response by the nurse is best?
a. "Squirt a small amount of soap water to clean your ears daily."
b. "Clean out as much earwax as you can."
c. "Put a couple of drops of mineral oil in your right ear."
d. "Can you describe the ear pain to me?"
d. "Can you describe the ear pain to me?"
The nurse's first response should be to get more information pertaining to the ear pain the patient is
experiencing. Signs and symptoms to be ascertained include the presence of drainage and odor, as
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,well as quality and severity of pain. Once all pertinent information is collected, an intervention can be
performed based on the assessment.
A is incorrect because the patient should not be taught to insert anything into the ears. Ears can be
cleaned daily with a damp washcloth, cleaning only as far in as the patient can comfortably reach with
one finger covered by the washcloth, applying light pressure only.
B is incorrect because not all earwax needs to be cleaned out of the ears; earwax has protective
mechanisms.
A patient is brought to the emergency department with sudden onset dyspnea. Which of the following
symptoms would the nurse expect to find upon assessment?
a. Respiratory rate of 26 bpm
b. Bradycardia
c. Clubbed fingers
d. Regular breathing pattern
a. Respiratory rate of 26 bpm
Dyspnea is difficulty breathing, which can be attributed to several different problems. A patient
experiencing dyspnea will most likely have an increased respiratory rate or tachypnea. If the brain is
not receiving enough oxygen, it will send signals to the respiratory muscles to increase the rate of
respiration in an attempt to meet oxygen demand. Hear rate may also increase as a compensatory
mechanism in response to decreased oxygenation.
The nurse has applied an oxygen mask to a patient experiencing dyspnea. Which of the following
assessments should the nurse make, initially, to determine if the oxygen therapy is effective?
a. Mucous membrane color
b. Arterial blood gas
c. Pulse oximetry
d. Lung sounds
c. Pulse oximetry
Pulse oximetry is a measurement of capillary arterial oxygen saturation. This method gives immediate
feedback on the effectiveness of oxygen therapy.
B is incorrect because obtaining an ABG takes time; this is not something the nurse can assess at the
bedside.
D is incorrect because lung sounds do not demonstrate the adequacy of oxygen therapy.
The patient is being treated with oxygen therapy via oxygen mask with reservoir (non-rebreather). If the
reservoir bag deflates, which of the following would the patient experience?
a. Increased oxygen levels
b. Elevated carbon dioxide levels
c. Drying of mucous membranes
d. Decreased respiratory rate
b. Elevated carbon dioxide levels
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, A non-rebreather oxygen mask delivers 80-100% oxygen at up to 12L per minute. This type of mask is
used to prevent increased carbon dioxide levels by blocking carbon dioxide from being inhaled from
the mask through special one-way valves. The reservoir should be 2/3 filled with oxygen during
inspiration. If it becomes deflated, the patient will experience an increased in carbon dioxide levels.
A patient admitted for acute pneumonia has a 15-year history of chronic lung disease and is unable to
clear respiratory secretions. Which of the following suctioning interventions is appropriate for this
patient?
a. Oropharyngeal
b. Nasopharyngeal
c. Endotracheal
d. Tracheal
a. Oropharyngeal
A patient who is unable to clear secretions would need oropharyngeal suction to remove thick mucus
in large amounts. This can be done with a Yankauer or tonsillar tip suction device. The patient should
be hyper-oxygenated before suctioning. The tip of the suction device should be moistened with sterile
saline before insertion. Wall suction should be set at 80-120 mmHg. Postural drainage and frequent
coughing and turning are also appropriate for this patient. Percussion and vibration can additionally
be performed during postural drainage to facilitate the effect of gravity drainage.
B is incorrect because nasopharyngeal suction would be inappropriate. If the nurse is able to suction
via the mouth, it is often less uncomfortable than through the patient's nasal passages.
C and D are incorrect because endotracheal suction and tracheal suction cannot be performed without
an endotracheal tube or tracheal airway, respectively.
A patient is admitted to the intensive care unit after a thoracotomy procedure. The vital signs at the end
of the procedure were: BP 118/72, HR 64, RR 18, SPO₂ 99%, and temperature 98.1°F (36.7°C). Which of
the following manifestations is most concerning to the nurse after a thoracotomy?
a. Increased mentation
b. Feeling of euphoria
c. Heart rate 89 and sinus rhythm with occasional premature ventricular contractions (PVC's)
d. Lethargy
d. Lethargy
A thoracotomy is an incision into the pleural space of the chest used by a surgeon to gain access to
major organs in the thorax. Thoracotomy incisions are extremely painful and can lead to shallow
breathing, which can cause hypoxia, atelectasis, or pneumonia. Common manifestations of hypoxia
include lethargy, restlessness, agitation, confusion, and anxiety. The nurse may also see tachycardia
and dysrhythmias related to hypoxia.
The nurse is caring for a patient with a tracheostomy whose pulse oximeter has decreased from 90% five
minutes ago to 85% currently. What is the priority action by the nurse?
a. Check for a pulse.
b. Assess blood pressure.
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