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.
6
, • Avoid leafy green vegetables: This is incorrect. Clients should not avoid leafy greens
altogether but should maintain a consistent intake because these foods are high in
vitamin K, which can affect warfarin's effectiveness.
• Take aspirin for headache relief: This is incorrect. Aspirin is also an anticoagulant and
can increase the risk of bleeding when taken with warfarin. Clients should use
alternative pain relief options and consult their healthcare provider.
Highlight Text: Fall Prevention Strategies
Scenario: A nurse is preparing a care plan for a client with a risk of falls.
• Question: "Which interventions should the nurse include to prevent falls? Select all
that apply."
o Options:
▪ Ensure adequate lighting in the client's room. (Correct Answer)
▪ Place the call light within the client's reach. (Correct Answer)
▪ Keep the bed in the highest position.
▪ Remove all assistive devices from the room.
▪ Apply non-slip socks to the client's feet. (Correct Answer)
Rationale:
• Ensure adequate lighting in the client's room: Proper lighting reduces the risk of
falls by improving visibility, especially for clients who may have visual impairments.
• Place the call light within the client's reach: This ensures that the client can easily
call for assistance if needed, reducing the likelihood of attempting to get up unassisted
and falling.
• Apply non-slip socks to the client's feet: Non-slip socks provide traction on
slippery surfaces, decreasing the risk of slipping and falling.
• Keep the bed in the highest position: Incorrect. Keeping the bed in a low
position minimizes the risk of injury if the client does fall out of bed.
7
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.
6
, • Avoid leafy green vegetables: This is incorrect. Clients should not avoid leafy greens
altogether but should maintain a consistent intake because these foods are high in
vitamin K, which can affect warfarin's effectiveness.
• Take aspirin for headache relief: This is incorrect. Aspirin is also an anticoagulant and
can increase the risk of bleeding when taken with warfarin. Clients should use
alternative pain relief options and consult their healthcare provider.
Highlight Text: Fall Prevention Strategies
Scenario: A nurse is preparing a care plan for a client with a risk of falls.
• Question: "Which interventions should the nurse include to prevent falls? Select all
that apply."
o Options:
▪ Ensure adequate lighting in the client's room. (Correct Answer)
▪ Place the call light within the client's reach. (Correct Answer)
▪ Keep the bed in the highest position.
▪ Remove all assistive devices from the room.
▪ Apply non-slip socks to the client's feet. (Correct Answer)
Rationale:
• Ensure adequate lighting in the client's room: Proper lighting reduces the risk of
falls by improving visibility, especially for clients who may have visual impairments.
• Place the call light within the client's reach: This ensures that the client can easily
call for assistance if needed, reducing the likelihood of attempting to get up unassisted
and falling.
• Apply non-slip socks to the client's feet: Non-slip socks provide traction on
slippery surfaces, decreasing the risk of slipping and falling.
• Keep the bed in the highest position: Incorrect. Keeping the bed in a low
position minimizes the risk of injury if the client does fall out of bed.
7
