Next Generation NCLEX Fundamentals of Nursing Study
Guide, High-Yield Exam Review Notes, Practice Questions
with Detailed Rationales, Clinical Judgment Case Studies,
and Complete RN Foundation Concepts for Guaranteed
NCLEX Success and Mastery
Question 1: A nurse is preparing to administer medication to a client. Which action should the
nurse take FIRST to ensure client safety?
A. Verify the client's identity using two identifiers
B. Check the medication against the medication administration record
C. Assess the client's allergy status
D. Explain the purpose of the medication to the client
CORRECT ANSWER: A. Verify the client's identity using two identifiers
Rationale: According to the National Patient Safety Goals and the "rights" of medication
administration, verifying client identity using two unique identifiers (e.g., name and date of
birth) is the first and most critical step before administering any medication. This prevents
wrong-patient errors. While checking the MAR, assessing allergies, and providing education are
essential, they follow after confirming the correct client.
Question 2: Which finding by the nurse indicates that a client is experiencing hypoxia?
A. Bradycardia and warm, dry skin
B. Tachycardia, restlessness, and cyanosis
C. Hypertension and flushed skin
D. Decreased respiratory rate and drowsiness
CORRECT ANSWER: B. Tachycardia, restlessness, and cyanosis
Rationale: Hypoxia triggers compensatory mechanisms including tachycardia (to increase
oxygen delivery), restlessness (early neurological sign), and cyanosis (late sign indicating
deoxygenated hemoglobin). Bradycardia, hypertension, or decreased respiratory rate are not
typical early indicators of hypoxia and may suggest other conditions or late-stage deterioration.
Question 3: A nurse is delegating tasks to unlicensed assistive personnel (UAP). Which task is
MOST appropriate for the UAP to perform?
A. Assessing a client's pain level using a pain scale
B. Administering a prescribed oral analgesic
C. Assisting a stable client with ambulation in the hallway
,D. Evaluating the effectiveness of a turning schedule for pressure injury prevention
CORRECT ANSWER: C. Assisting a stable client with ambulation in the hallway
Rationale: Unlicensed assistive personnel (UAP) can perform routine, non-invasive tasks for
stable clients that do not require clinical judgment. Assisting with ambulation falls within the
UAP scope. Assessment, medication administration, and evaluation require licensed nursing
judgment and cannot be delegated.
Question 4: The nurse is caring for a client with a new prescription for warfarin. Which client
statement indicates a need for further teaching?
A. "I will use an electric razor instead of a blade razor."
B. "I will avoid foods high in vitamin K like spinach and broccoli."
C. "I can take ibuprofen for headaches if needed."
D. "I will report any unusual bruising or bleeding to my provider."
CORRECT ANSWER: C. "I can take ibuprofen for headaches if needed."
Rationale: Ibuprofen and other NSAIDs increase the risk of bleeding when taken with warfarin
due to antiplatelet effects and gastric irritation. Clients on warfarin should use acetaminophen
for pain relief unless otherwise directed. The other statements reflect appropriate
understanding of warfarin safety measures.
Question 5: Which action by the nurse demonstrates proper hand hygiene according to CDC
guidelines?
A. Washing hands with soap and water for at least 10 seconds
B. Using alcohol-based hand rub when hands are visibly soiled
C. Washing hands with soap and water after caring for a client with Clostridioides difficile
D. Applying hand lotion before performing hand hygiene
CORRECT ANSWER: C. Washing hands with soap and water after caring for a client with
Clostridioides difficile
Rationale: C. difficile spores are not killed by alcohol-based hand rubs; soap and water
mechanical friction is required to remove spores. CDC recommends washing hands with soap
and water for at least 20 seconds (not 10), using alcohol rub only when hands are not visibly
soiled, and avoiding lotion before hand hygiene as it may interfere with antimicrobial efficacy.
Question 6: A nurse is preparing to insert an indwelling urinary catheter. Which intervention is
MOST important to prevent catheter-associated urinary tract infection (CAUTI)?
,A. Using sterile technique during insertion
B. Securing the catheter to the client's thigh
C. Emptying the drainage bag every 8 hours
D. Performing perineal care with antiseptic solution daily
CORRECT ANSWER: A. Using sterile technique during insertion
Rationale: Sterile technique during catheter insertion is the single most critical intervention to
prevent introduction of pathogens into the urinary tract. While securing the catheter, regular
emptying, and perineal care support CAUTI prevention, they are secondary to maintaining
sterility at the point of entry.
Question 7: The nurse is assessing a client's pressure injury. Which stage is characterized by full-
thickness skin loss with visible subcutaneous fat but no exposure of bone, tendon, or muscle?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
CORRECT ANSWER: C. Stage 3
Rationale: Stage 3 pressure injuries involve full-thickness skin loss with visible subcutaneous fat;
however, bone, tendon, or muscle are not exposed. Stage 1 shows non-blanchable erythema;
Stage 2 involves partial-thickness loss; Stage 4 includes exposed bone, tendon, or muscle.
Unstageable and deep tissue injury are additional categories.
Question 8: Which assessment finding should the nurse recognize as a sign of fluid volume
deficit?
A. Bounding peripheral pulses
B. Distended neck veins
C. Dry mucous membranes and poor skin turgor
D. Crackles in lung bases
CORRECT ANSWER: C. Dry mucous membranes and poor skin turgor
Rationale: Dry mucous membranes and decreased skin turgor are classic signs of
dehydration/fluid volume deficit. Bounding pulses, distended neck veins, and crackles indicate
fluid volume excess. Assessing for these signs helps guide fluid replacement or restriction
interventions.
, Question 9: A nurse is teaching a client about deep breathing and coughing exercises
postoperatively. Which statement by the client indicates understanding?
A. "I should take shallow breaths to avoid pain."
B. "I will cough forcefully without supporting my incision."
C. "I should inhale slowly through my nose, hold briefly, then exhale through pursed lips."
D. "I only need to do these exercises if I feel short of breath."
CORRECT ANSWER: C. "I should inhale slowly through my nose, hold briefly, then exhale
through pursed lips."
Rationale: Proper deep breathing technique involves slow nasal inhalation, brief hold to
maximize alveolar expansion, and controlled exhalation through pursed lips to maintain airway
pressure and prevent atelectasis. Shallow breathing, unsupported coughing, or performing
exercises only when symptomatic increase postoperative pulmonary complication risk.
Question 10: The nurse is caring for a client receiving oxygen via nasal cannula at 4 L/min.
Which action should the nurse take to ensure client safety?
A. Apply water-based lubricant to the nares
B. Post a "No Smoking" sign at the bedside
C. Adjust the flow rate based on client comfort
D. Remove the cannula during meals
CORRECT ANSWER: B. Post a "No Smoking" sign at the bedside
Rationale: Oxygen supports combustion; posting "No Smoking" signs is a critical fire safety
measure. Water-based lubricants (not petroleum-based) may be used for nares, but fire safety
takes priority. Flow rates must follow provider orders, and oxygen should not be removed
during meals unless specifically ordered, as hypoxia risk may increase.
Question 11: Which finding should the nurse report immediately for a client receiving
intravenous potassium chloride?
A. Serum potassium level of 4.0 mEq/L
B. Urine output of 40 mL/hr
C. Burning sensation at the IV site
D. Heart rate of 88 beats per minute
CORRECT ANSWER: C. Burning sensation at the IV site
Guide, High-Yield Exam Review Notes, Practice Questions
with Detailed Rationales, Clinical Judgment Case Studies,
and Complete RN Foundation Concepts for Guaranteed
NCLEX Success and Mastery
Question 1: A nurse is preparing to administer medication to a client. Which action should the
nurse take FIRST to ensure client safety?
A. Verify the client's identity using two identifiers
B. Check the medication against the medication administration record
C. Assess the client's allergy status
D. Explain the purpose of the medication to the client
CORRECT ANSWER: A. Verify the client's identity using two identifiers
Rationale: According to the National Patient Safety Goals and the "rights" of medication
administration, verifying client identity using two unique identifiers (e.g., name and date of
birth) is the first and most critical step before administering any medication. This prevents
wrong-patient errors. While checking the MAR, assessing allergies, and providing education are
essential, they follow after confirming the correct client.
Question 2: Which finding by the nurse indicates that a client is experiencing hypoxia?
A. Bradycardia and warm, dry skin
B. Tachycardia, restlessness, and cyanosis
C. Hypertension and flushed skin
D. Decreased respiratory rate and drowsiness
CORRECT ANSWER: B. Tachycardia, restlessness, and cyanosis
Rationale: Hypoxia triggers compensatory mechanisms including tachycardia (to increase
oxygen delivery), restlessness (early neurological sign), and cyanosis (late sign indicating
deoxygenated hemoglobin). Bradycardia, hypertension, or decreased respiratory rate are not
typical early indicators of hypoxia and may suggest other conditions or late-stage deterioration.
Question 3: A nurse is delegating tasks to unlicensed assistive personnel (UAP). Which task is
MOST appropriate for the UAP to perform?
A. Assessing a client's pain level using a pain scale
B. Administering a prescribed oral analgesic
C. Assisting a stable client with ambulation in the hallway
,D. Evaluating the effectiveness of a turning schedule for pressure injury prevention
CORRECT ANSWER: C. Assisting a stable client with ambulation in the hallway
Rationale: Unlicensed assistive personnel (UAP) can perform routine, non-invasive tasks for
stable clients that do not require clinical judgment. Assisting with ambulation falls within the
UAP scope. Assessment, medication administration, and evaluation require licensed nursing
judgment and cannot be delegated.
Question 4: The nurse is caring for a client with a new prescription for warfarin. Which client
statement indicates a need for further teaching?
A. "I will use an electric razor instead of a blade razor."
B. "I will avoid foods high in vitamin K like spinach and broccoli."
C. "I can take ibuprofen for headaches if needed."
D. "I will report any unusual bruising or bleeding to my provider."
CORRECT ANSWER: C. "I can take ibuprofen for headaches if needed."
Rationale: Ibuprofen and other NSAIDs increase the risk of bleeding when taken with warfarin
due to antiplatelet effects and gastric irritation. Clients on warfarin should use acetaminophen
for pain relief unless otherwise directed. The other statements reflect appropriate
understanding of warfarin safety measures.
Question 5: Which action by the nurse demonstrates proper hand hygiene according to CDC
guidelines?
A. Washing hands with soap and water for at least 10 seconds
B. Using alcohol-based hand rub when hands are visibly soiled
C. Washing hands with soap and water after caring for a client with Clostridioides difficile
D. Applying hand lotion before performing hand hygiene
CORRECT ANSWER: C. Washing hands with soap and water after caring for a client with
Clostridioides difficile
Rationale: C. difficile spores are not killed by alcohol-based hand rubs; soap and water
mechanical friction is required to remove spores. CDC recommends washing hands with soap
and water for at least 20 seconds (not 10), using alcohol rub only when hands are not visibly
soiled, and avoiding lotion before hand hygiene as it may interfere with antimicrobial efficacy.
Question 6: A nurse is preparing to insert an indwelling urinary catheter. Which intervention is
MOST important to prevent catheter-associated urinary tract infection (CAUTI)?
,A. Using sterile technique during insertion
B. Securing the catheter to the client's thigh
C. Emptying the drainage bag every 8 hours
D. Performing perineal care with antiseptic solution daily
CORRECT ANSWER: A. Using sterile technique during insertion
Rationale: Sterile technique during catheter insertion is the single most critical intervention to
prevent introduction of pathogens into the urinary tract. While securing the catheter, regular
emptying, and perineal care support CAUTI prevention, they are secondary to maintaining
sterility at the point of entry.
Question 7: The nurse is assessing a client's pressure injury. Which stage is characterized by full-
thickness skin loss with visible subcutaneous fat but no exposure of bone, tendon, or muscle?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
CORRECT ANSWER: C. Stage 3
Rationale: Stage 3 pressure injuries involve full-thickness skin loss with visible subcutaneous fat;
however, bone, tendon, or muscle are not exposed. Stage 1 shows non-blanchable erythema;
Stage 2 involves partial-thickness loss; Stage 4 includes exposed bone, tendon, or muscle.
Unstageable and deep tissue injury are additional categories.
Question 8: Which assessment finding should the nurse recognize as a sign of fluid volume
deficit?
A. Bounding peripheral pulses
B. Distended neck veins
C. Dry mucous membranes and poor skin turgor
D. Crackles in lung bases
CORRECT ANSWER: C. Dry mucous membranes and poor skin turgor
Rationale: Dry mucous membranes and decreased skin turgor are classic signs of
dehydration/fluid volume deficit. Bounding pulses, distended neck veins, and crackles indicate
fluid volume excess. Assessing for these signs helps guide fluid replacement or restriction
interventions.
, Question 9: A nurse is teaching a client about deep breathing and coughing exercises
postoperatively. Which statement by the client indicates understanding?
A. "I should take shallow breaths to avoid pain."
B. "I will cough forcefully without supporting my incision."
C. "I should inhale slowly through my nose, hold briefly, then exhale through pursed lips."
D. "I only need to do these exercises if I feel short of breath."
CORRECT ANSWER: C. "I should inhale slowly through my nose, hold briefly, then exhale
through pursed lips."
Rationale: Proper deep breathing technique involves slow nasal inhalation, brief hold to
maximize alveolar expansion, and controlled exhalation through pursed lips to maintain airway
pressure and prevent atelectasis. Shallow breathing, unsupported coughing, or performing
exercises only when symptomatic increase postoperative pulmonary complication risk.
Question 10: The nurse is caring for a client receiving oxygen via nasal cannula at 4 L/min.
Which action should the nurse take to ensure client safety?
A. Apply water-based lubricant to the nares
B. Post a "No Smoking" sign at the bedside
C. Adjust the flow rate based on client comfort
D. Remove the cannula during meals
CORRECT ANSWER: B. Post a "No Smoking" sign at the bedside
Rationale: Oxygen supports combustion; posting "No Smoking" signs is a critical fire safety
measure. Water-based lubricants (not petroleum-based) may be used for nares, but fire safety
takes priority. Flow rates must follow provider orders, and oxygen should not be removed
during meals unless specifically ordered, as hypoxia risk may increase.
Question 11: Which finding should the nurse report immediately for a client receiving
intravenous potassium chloride?
A. Serum potassium level of 4.0 mEq/L
B. Urine output of 40 mL/hr
C. Burning sensation at the IV site
D. Heart rate of 88 beats per minute
CORRECT ANSWER: C. Burning sensation at the IV site
