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Comprehensive NCLEX NGN Practice Questions for FUNDAMENTALS OF NURSING

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Comprehensive NCLEX NGN Practice Questions for FUNDAMENTALS OF NURSING A Guide to Critical Thinking and Clinical Judgment Chapter 1: Nursing Assessment and Patient Safety Case Study: Diabetic Ketoacidosis (DKA) Management Scenario: A client with a history of diabetes mellitus presents with blurred vision, thirst, and frequent urination. • Question: "What is the nurse's priority intervention?" o Options: ▪ Administer prescribed insulin. (Correct Answer) ▪ Restrict fluid intake. ▪ Encourage the client to rest. ▪ Apply a cool compress to the forehead. Rationale: The symptoms described (blurred vision, thirst, and frequent urination) are indicative of hyperglycemia, which can lead to diabetic ketoacidosis (DKA) if not promptly treated. Administering insulin is the priority intervention because it helps lower the blood glucose level, preventing further complications such as DKA. Restricting fluid intake is incorrect because clients with hyperglycemia often require fluids to prevent dehydration. Encouraging rest and applying a cool compress may provide comfort but do not address the underlying hyperglycemia. 5 Extended Multiple Response: Warfarin Safety Precautions Scenario: A nurse is providing discharge instructions to a client who has been prescribed warfarin. • Question: "Which instructions should the nurse include to ensure the client's safety? Select all that apply." o Options: ▪ Avoid leafy green vegetables. ▪ Use an electric razor for shaving. (Correct Answer) ▪ Monitor for signs of bleeding. (Correct Answer) ▪ Take aspirin for headache relief. ▪ Keep scheduled blood test appointments. (Correct Answer) Rationale: • Use an electric razor for shaving: Warfarin is an anticoagulant, which increases the risk of bleeding. Using an electric razor instead of a traditional one reduces the risk of cuts and bleeding. • Monitor for signs of bleeding: Clients on warfarin are at risk for bleeding. They should be educated to monitor for signs such as bruising, nosebleeds, and blood in the urine or stool. • Keep scheduled blood test appointments: Regular blood tests (INR/PT) are necessary to monitor the therapeutic level of warfarin and adjust the dosage as needed to reduce the risk of either bleeding or clotting.

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