Next Generation NCLEX (NGN) Fundamentals of Nursing
Study Guide | Comprehensive NCLEX-RN Prep Notes,
Practice Questions, Clinical Judgment Cases & Exam
Success Bundle
Question 1: A nurse is caring for a client who is at risk for falls. Which intervention should the
nurse implement FIRST to promote client safety?
A. Place the client's belongings within easy reach
B. Keep the bed in the lowest position with brakes locked
C. Apply a bed alarm to alert staff of movement
D. Educate the client about calling for assistance before ambulating
CORRECT ANSWER: B. Keep the bed in the lowest position with brakes locked
Rationale: Keeping the bed in the lowest position with brakes locked is the foundational
environmental safety intervention that should be implemented first for any client at risk for
falls. This action creates a physical barrier to injury by minimizing the distance of a potential fall
and preventing bed movement. While the other options are appropriate fall prevention
strategies, environmental modification takes priority as it provides immediate, continuous
protection regardless of client compliance or staff response time.
Question 2: A nurse is performing hand hygiene after caring for a client with Clostridioides
difficile infection. Which action indicates the nurse understands proper technique?
A. Using an alcohol-based hand sanitizer for 20 seconds
B. Washing hands with soap and water for at least 20 seconds
C. Rinsing hands with water only after glove removal
D. Applying hand lotion before donning clean gloves
CORRECT ANSWER: B. Washing hands with soap and water for at least 20 seconds
Rationale: C. difficile forms spores that are not effectively killed by alcohol-based hand
sanitizers. Soap and water mechanically remove spores from the hands through friction and
rinsing, making it the required method for hand hygiene after caring for clients with C. difficile
infection. Alcohol-based sanitizers remain appropriate for most other clinical situations, but
spore-forming organisms require this specific technique.
Question 3: A nurse is assessing a client's vital signs and notes a temperature of 38.5°C
(101.3°F), pulse of 110 beats/min, respirations of 24/min, and blood pressure of 90/60 mm Hg.
Which action should the nurse take FIRST?
A. Administer an antipyretic medication as prescribed
B. Notify the healthcare provider of the findings
,C. Assess the client for additional signs of infection
D. Document the vital signs in the electronic health record
CORRECT ANSWER: C. Assess the client for additional signs of infection
Rationale: Before implementing interventions or notifying providers, the nurse must gather
additional assessment data to recognize relevant cues and analyze the clinical picture. The
elevated temperature, tachycardia, tachypnea, and hypotension suggest possible sepsis or
systemic infection, but further assessment (e.g., lung sounds, wound inspection, mental status)
is essential to prioritize hypotheses and guide appropriate actions. This aligns with the NCSBN
Clinical Judgment Measurement Model's "recognize and analyze cues" steps.
Question 4: A nurse is preparing to administer a scheduled oral medication. The client states,
"I've never seen that pill before." Which action should the nurse take?
A. Reassure the client that the medication is correct and administer it
B. Withhold the medication and verify the order with the prescriber
C. Check the medication administration record and compare to the medication label
D. Ask another nurse to confirm the medication before administration
CORRECT ANSWER: C. Check the medication administration record and compare to the
medication label
Rationale: When a client questions a medication, the nurse's first action is to verify the "rights"
of medication administration by checking the medication administration record against the
medication label and the original order. This independent verification addresses the client's
concern while maintaining safety. Withholding and contacting the prescriber or involving
another nurse may be subsequent steps if discrepancies are found, but initial verification is the
nurse's responsibility.
Question 5: A nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which task is
appropriate for the UAP to perform?
A. Assessing a client's pain level using a numeric scale
B. Administering a prescribed oral analgesic medication
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 may perform tasks that involve routine, predictable
care for stable clients, such as assisting with ambulation, bathing, or vital signs. Assessment,
,medication administration, and evaluation require the clinical judgment and licensure of a
registered nurse. Delegating appropriately ensures client safety while optimizing team
efficiency.
Question 6: A nurse is caring for a client with a new tracheostomy. Which assessment finding
requires IMMEDIATE intervention?
A. Small amount of clear secretions at the stoma site
B. Client coughing during suctioning procedure
C. Subcutaneous emphysema noted around the neck
D. Tracheostomy tube secured with clean ties
CORRECT ANSWER: C. Subcutaneous emphysema noted around the neck
Rationale: Subcutaneous emphysema (air trapped under the skin) around a new tracheostomy
site may indicate tube displacement, tracheal perforation, or improper placement, which can
compromise the airway. This finding requires immediate assessment of tube position,
oxygenation status, and potential notification of the provider. The other findings are expected
or manageable with routine care.
Question 7: A nurse is teaching a client about proper use of an incentive spirometer. Which
statement by the client indicates understanding?
A. "I will blow into the mouthpiece as hard as I can."
B. "I should use this device only when I feel short of breath."
C. "I will inhale slowly and deeply to raise the indicator, then hold my breath."
D. "I can skip using this if I am able to walk in the hallway."
CORRECT ANSWER: C. "I will inhale slowly and deeply to raise the indicator, then hold my
breath."
Rationale: Proper incentive spirometer technique involves slow, deep inhalation to elevate the
indicator, followed by a 3-5 second breath hold to maximize alveolar expansion and prevent
atelectasis. Exhaling forcefully (option A) is incorrect; the device measures inhalation.
Scheduled use (not just when symptomatic) and continuation despite ambulation are essential
for postoperative pulmonary hygiene.
Question 8: A nurse is reviewing a client's medication list and notes the client takes warfarin
daily. Which food should the nurse instruct the client to consume consistently?
A. Spinach
B. Grapefruit
, C. Lean beef
D. Whole grain bread
CORRECT ANSWER: A. Spinach
Rationale: Warfarin's anticoagulant effect is antagonized by vitamin K, which is abundant in
green leafy vegetables like spinach. Clients should not avoid these foods but should consume
them in consistent amounts daily to maintain stable INR levels. Sudden increases or decreases
in vitamin K intake can cause dangerous fluctuations in anticoagulation. Grapefruit interacts
with many medications but not significantly with warfarin.
Question 9: A nurse is caring for a client who is NPO for scheduled surgery. The client requests a
sip of water. Which response by the nurse is MOST appropriate?
A. "I can give you a small sip since you are thirsty."
B. "Let me check with the surgeon to see if that is allowed."
C. "I understand you are thirsty, but nothing by mouth helps keep you safe during anesthesia."
D. "You can have ice chips to help with the dryness."
CORRECT ANSWER: C. "I understand you are thirsty, but nothing by mouth helps keep you safe
during anesthesia."
Rationale: Maintaining NPO status before surgery is critical to reduce the risk of aspiration
during anesthesia. The nurse should provide a clear, empathetic explanation of the rationale
rather than offering exceptions (ice chips or sips) or deferring unnecessarily. While checking
with the provider may be appropriate in some contexts, the standard NPO guidelines are well-
established, and the nurse can confidently educate the client on safety principles.
Question 10: A nurse is assessing a client's surgical wound and notes redness, warmth, swelling,
and purulent drainage. Which action should the nurse take FIRST?
A. Apply a new sterile dressing to the wound
B. Obtain a wound culture as prescribed
C. Notify the healthcare provider of the findings
D. Document the assessment findings in the chart
CORRECT ANSWER: C. Notify the healthcare provider of the findings
Rationale: The presence of redness, warmth, swelling, and purulent drainage indicates a
probable surgical site infection requiring prompt medical evaluation and potential intervention
(e.g., antibiotics, wound revision). While obtaining a culture and documenting are important,
Study Guide | Comprehensive NCLEX-RN Prep Notes,
Practice Questions, Clinical Judgment Cases & Exam
Success Bundle
Question 1: A nurse is caring for a client who is at risk for falls. Which intervention should the
nurse implement FIRST to promote client safety?
A. Place the client's belongings within easy reach
B. Keep the bed in the lowest position with brakes locked
C. Apply a bed alarm to alert staff of movement
D. Educate the client about calling for assistance before ambulating
CORRECT ANSWER: B. Keep the bed in the lowest position with brakes locked
Rationale: Keeping the bed in the lowest position with brakes locked is the foundational
environmental safety intervention that should be implemented first for any client at risk for
falls. This action creates a physical barrier to injury by minimizing the distance of a potential fall
and preventing bed movement. While the other options are appropriate fall prevention
strategies, environmental modification takes priority as it provides immediate, continuous
protection regardless of client compliance or staff response time.
Question 2: A nurse is performing hand hygiene after caring for a client with Clostridioides
difficile infection. Which action indicates the nurse understands proper technique?
A. Using an alcohol-based hand sanitizer for 20 seconds
B. Washing hands with soap and water for at least 20 seconds
C. Rinsing hands with water only after glove removal
D. Applying hand lotion before donning clean gloves
CORRECT ANSWER: B. Washing hands with soap and water for at least 20 seconds
Rationale: C. difficile forms spores that are not effectively killed by alcohol-based hand
sanitizers. Soap and water mechanically remove spores from the hands through friction and
rinsing, making it the required method for hand hygiene after caring for clients with C. difficile
infection. Alcohol-based sanitizers remain appropriate for most other clinical situations, but
spore-forming organisms require this specific technique.
Question 3: A nurse is assessing a client's vital signs and notes a temperature of 38.5°C
(101.3°F), pulse of 110 beats/min, respirations of 24/min, and blood pressure of 90/60 mm Hg.
Which action should the nurse take FIRST?
A. Administer an antipyretic medication as prescribed
B. Notify the healthcare provider of the findings
,C. Assess the client for additional signs of infection
D. Document the vital signs in the electronic health record
CORRECT ANSWER: C. Assess the client for additional signs of infection
Rationale: Before implementing interventions or notifying providers, the nurse must gather
additional assessment data to recognize relevant cues and analyze the clinical picture. The
elevated temperature, tachycardia, tachypnea, and hypotension suggest possible sepsis or
systemic infection, but further assessment (e.g., lung sounds, wound inspection, mental status)
is essential to prioritize hypotheses and guide appropriate actions. This aligns with the NCSBN
Clinical Judgment Measurement Model's "recognize and analyze cues" steps.
Question 4: A nurse is preparing to administer a scheduled oral medication. The client states,
"I've never seen that pill before." Which action should the nurse take?
A. Reassure the client that the medication is correct and administer it
B. Withhold the medication and verify the order with the prescriber
C. Check the medication administration record and compare to the medication label
D. Ask another nurse to confirm the medication before administration
CORRECT ANSWER: C. Check the medication administration record and compare to the
medication label
Rationale: When a client questions a medication, the nurse's first action is to verify the "rights"
of medication administration by checking the medication administration record against the
medication label and the original order. This independent verification addresses the client's
concern while maintaining safety. Withholding and contacting the prescriber or involving
another nurse may be subsequent steps if discrepancies are found, but initial verification is the
nurse's responsibility.
Question 5: A nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which task is
appropriate for the UAP to perform?
A. Assessing a client's pain level using a numeric scale
B. Administering a prescribed oral analgesic medication
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 may perform tasks that involve routine, predictable
care for stable clients, such as assisting with ambulation, bathing, or vital signs. Assessment,
,medication administration, and evaluation require the clinical judgment and licensure of a
registered nurse. Delegating appropriately ensures client safety while optimizing team
efficiency.
Question 6: A nurse is caring for a client with a new tracheostomy. Which assessment finding
requires IMMEDIATE intervention?
A. Small amount of clear secretions at the stoma site
B. Client coughing during suctioning procedure
C. Subcutaneous emphysema noted around the neck
D. Tracheostomy tube secured with clean ties
CORRECT ANSWER: C. Subcutaneous emphysema noted around the neck
Rationale: Subcutaneous emphysema (air trapped under the skin) around a new tracheostomy
site may indicate tube displacement, tracheal perforation, or improper placement, which can
compromise the airway. This finding requires immediate assessment of tube position,
oxygenation status, and potential notification of the provider. The other findings are expected
or manageable with routine care.
Question 7: A nurse is teaching a client about proper use of an incentive spirometer. Which
statement by the client indicates understanding?
A. "I will blow into the mouthpiece as hard as I can."
B. "I should use this device only when I feel short of breath."
C. "I will inhale slowly and deeply to raise the indicator, then hold my breath."
D. "I can skip using this if I am able to walk in the hallway."
CORRECT ANSWER: C. "I will inhale slowly and deeply to raise the indicator, then hold my
breath."
Rationale: Proper incentive spirometer technique involves slow, deep inhalation to elevate the
indicator, followed by a 3-5 second breath hold to maximize alveolar expansion and prevent
atelectasis. Exhaling forcefully (option A) is incorrect; the device measures inhalation.
Scheduled use (not just when symptomatic) and continuation despite ambulation are essential
for postoperative pulmonary hygiene.
Question 8: A nurse is reviewing a client's medication list and notes the client takes warfarin
daily. Which food should the nurse instruct the client to consume consistently?
A. Spinach
B. Grapefruit
, C. Lean beef
D. Whole grain bread
CORRECT ANSWER: A. Spinach
Rationale: Warfarin's anticoagulant effect is antagonized by vitamin K, which is abundant in
green leafy vegetables like spinach. Clients should not avoid these foods but should consume
them in consistent amounts daily to maintain stable INR levels. Sudden increases or decreases
in vitamin K intake can cause dangerous fluctuations in anticoagulation. Grapefruit interacts
with many medications but not significantly with warfarin.
Question 9: A nurse is caring for a client who is NPO for scheduled surgery. The client requests a
sip of water. Which response by the nurse is MOST appropriate?
A. "I can give you a small sip since you are thirsty."
B. "Let me check with the surgeon to see if that is allowed."
C. "I understand you are thirsty, but nothing by mouth helps keep you safe during anesthesia."
D. "You can have ice chips to help with the dryness."
CORRECT ANSWER: C. "I understand you are thirsty, but nothing by mouth helps keep you safe
during anesthesia."
Rationale: Maintaining NPO status before surgery is critical to reduce the risk of aspiration
during anesthesia. The nurse should provide a clear, empathetic explanation of the rationale
rather than offering exceptions (ice chips or sips) or deferring unnecessarily. While checking
with the provider may be appropriate in some contexts, the standard NPO guidelines are well-
established, and the nurse can confidently educate the client on safety principles.
Question 10: A nurse is assessing a client's surgical wound and notes redness, warmth, swelling,
and purulent drainage. Which action should the nurse take FIRST?
A. Apply a new sterile dressing to the wound
B. Obtain a wound culture as prescribed
C. Notify the healthcare provider of the findings
D. Document the assessment findings in the chart
CORRECT ANSWER: C. Notify the healthcare provider of the findings
Rationale: The presence of redness, warmth, swelling, and purulent drainage indicates a
probable surgical site infection requiring prompt medical evaluation and potential intervention
(e.g., antibiotics, wound revision). While obtaining a culture and documenting are important,
