NCLEX NGN RN EXAM 2 (WITH ALL
QUESTIONS FORMART) NEW ACTUAL
EXAM ALL 150 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH
DETAILED RATIONALES|ALREADY
GRADED A+
Question 1 – Extended Multiple Response (Select all that apply)
A nurse in the emergency department is assessing a client who presents
with shortness of breath, chest pressure, and diaphoresis. The client’s ECG
shows ST-segment elevation in leads II, III, and aVF. Which interventions
should the nurse initiate immediately? (Select all that apply.)
1. Administer sublingual nitroglycerin
2. Obtain a 12-lead ECG
3. Prepare for percutaneous coronary intervention (PCI)
4. Give 324 mg of chewable aspirin
5. Apply oxygen at 2 L/min via nasal cannula if SpO₂ < 90%
Correct answers: 2, 3, 4, 5
Rationale:
Option 2 – A 12-lead ECG confirms STEMI location and guides treatment;
serial ECGs may be needed.
Option 3 – For inferior STEMI (II, III, aVF), timely PCI is the standard of care.
Option 4 – Aspirin 324 mg chewed rapidly inhibits platelet aggregation
and reduces mortality.
Option 5 – Supplemental oxygen is given only if SpO₂ < 90% (current
guidelines avoid routine oxygen).
, Option 1 – Sublingual nitroglycerin is contraindicated in inferior STEMI with
possible right ventricular involvement because it can cause severe
hypotension.
Question 2 – Bow-tie (Drag the appropriate options to the correct
categories)
Scenario: A nurse is caring for a client with heart failure who has gained 3
kg in 24 hours, has crackles in bilateral lung bases, and reports shortness of
breath when walking to the bathroom.
Drag the one condition (center of bow-tie), two risk factors (left side),
and two interventions (right side).
Options:
Conditions: Fluid volume deficit, Fluid volume excess, Electrolyte imbalance
Risk factors: High sodium intake, Left ventricular dysfunction, Diuretic
overuse, Decreased protein intake
Interventions: Restrict oral fluids to 1 L/day, Administer IV furosemide,
Elevate head of bed, Encourage bed rest, Increase IV normal saline
Correct placement:
Center (Condition): Fluid volume excess
Left (Risk factors): High sodium intake, Left ventricular dysfunction
Right (Interventions): Administer IV furosemide, Elevate head of bed
Rationale:
Fluid volume excess (hypervolemia) in HF causes weight gain, crackles, and
dyspnea. High sodium intake worsens retention; left ventricular dysfunction
reduces pumping ability. IV furosemide removes excess fluid, and head
elevation improves breathing. Fluid restriction may be used but is not the
,priority for acute decompensation. Bed rest helps but is less specific than
diuresis and position.
Question 3 – Drop-down (Cloze)
A nurse is preparing to administer 4 mg of intravenous morphine to a client
with acute myocardial infarction who reports severe chest pain (8/10).
Before administration, the nurse must check the client’s respiratory rate.
The medication should be withheld if the respiratory rate is less than ______
breaths per minute.
Drop-down options:
A) 8
B) 10
C) 12
D) 16
Correct answer: C) 12
Rationale:
Morphine can cause respiratory depression. Standard practice holds the
dose if respiratory rate is < 12/min. Some institutions use < 10/min, but the
NCLEX generally expects 12/min as the threshold for holding a routine
opioid dose.
Question 4 – Highlighting (Identify the findings that require
immediate follow-up)
Scenario: A nurse receives shift report on four clients. Click to highlight
the three findings that require immediate notification of the provider.
, Client A: Post-op day 1 after colectomy, temperature 38.1°C (100.6°F), HR
92, BP 118/76
Client B: Received insulin lispro at 07:30, now 09:00, blood glucose 55
mg/dL, diaphoretic, confused
Client C: Chronic kidney disease, potassium 5.9 mEq/L, no ECG changes
Client D: Hip replacement, reports incisional pain 5/10, morphine given 30
minutes ago
Highlighted answers: Client B (hypoglycemia with neuro symptoms),
Client C (potassium 5.9 – hyperkalemia risk), Client A (low-grade fever may
be expected, but post-op fever could indicate infection; however, among
options, B and C are most urgent, but question asks for three, so including
A is plausible in some contexts – but rational answer: B, C, and D? Actually
D is pain controlled. Let’s adjust: The three most urgent are B, C, and A?
No – on NCLEX, hypoglycemia and hyperkalemia are priorities. Third finding
could be fever if >38.3°C but this is 38.1. Let’s re-do with standard answer:
Correct highlights:
Client B (hypoglycemia with confusion – emergency)
Client C (K+ 5.9 – risk of cardiac arrest)
Client A (38.1°C is mild; but in post-op, it could be early sepsis – many
NCLEX questions would include fever >38°C as urgent)
Better answer for exam purposes: Highlight B, C, and A because a new
fever post-colectomy requires evaluation for anastomotic leak or infection.
Rationale: Hypoglycemia with altered mental status needs immediate
dextrose; hyperkalemia >5.5 needs treatment; post-op fever >38°C requires
provider notification. Client D’s pain is expected and treated.
Question 5 – Drag and Drop (Ordering/Prioritizing)
QUESTIONS FORMART) NEW ACTUAL
EXAM ALL 150 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH
DETAILED RATIONALES|ALREADY
GRADED A+
Question 1 – Extended Multiple Response (Select all that apply)
A nurse in the emergency department is assessing a client who presents
with shortness of breath, chest pressure, and diaphoresis. The client’s ECG
shows ST-segment elevation in leads II, III, and aVF. Which interventions
should the nurse initiate immediately? (Select all that apply.)
1. Administer sublingual nitroglycerin
2. Obtain a 12-lead ECG
3. Prepare for percutaneous coronary intervention (PCI)
4. Give 324 mg of chewable aspirin
5. Apply oxygen at 2 L/min via nasal cannula if SpO₂ < 90%
Correct answers: 2, 3, 4, 5
Rationale:
Option 2 – A 12-lead ECG confirms STEMI location and guides treatment;
serial ECGs may be needed.
Option 3 – For inferior STEMI (II, III, aVF), timely PCI is the standard of care.
Option 4 – Aspirin 324 mg chewed rapidly inhibits platelet aggregation
and reduces mortality.
Option 5 – Supplemental oxygen is given only if SpO₂ < 90% (current
guidelines avoid routine oxygen).
, Option 1 – Sublingual nitroglycerin is contraindicated in inferior STEMI with
possible right ventricular involvement because it can cause severe
hypotension.
Question 2 – Bow-tie (Drag the appropriate options to the correct
categories)
Scenario: A nurse is caring for a client with heart failure who has gained 3
kg in 24 hours, has crackles in bilateral lung bases, and reports shortness of
breath when walking to the bathroom.
Drag the one condition (center of bow-tie), two risk factors (left side),
and two interventions (right side).
Options:
Conditions: Fluid volume deficit, Fluid volume excess, Electrolyte imbalance
Risk factors: High sodium intake, Left ventricular dysfunction, Diuretic
overuse, Decreased protein intake
Interventions: Restrict oral fluids to 1 L/day, Administer IV furosemide,
Elevate head of bed, Encourage bed rest, Increase IV normal saline
Correct placement:
Center (Condition): Fluid volume excess
Left (Risk factors): High sodium intake, Left ventricular dysfunction
Right (Interventions): Administer IV furosemide, Elevate head of bed
Rationale:
Fluid volume excess (hypervolemia) in HF causes weight gain, crackles, and
dyspnea. High sodium intake worsens retention; left ventricular dysfunction
reduces pumping ability. IV furosemide removes excess fluid, and head
elevation improves breathing. Fluid restriction may be used but is not the
,priority for acute decompensation. Bed rest helps but is less specific than
diuresis and position.
Question 3 – Drop-down (Cloze)
A nurse is preparing to administer 4 mg of intravenous morphine to a client
with acute myocardial infarction who reports severe chest pain (8/10).
Before administration, the nurse must check the client’s respiratory rate.
The medication should be withheld if the respiratory rate is less than ______
breaths per minute.
Drop-down options:
A) 8
B) 10
C) 12
D) 16
Correct answer: C) 12
Rationale:
Morphine can cause respiratory depression. Standard practice holds the
dose if respiratory rate is < 12/min. Some institutions use < 10/min, but the
NCLEX generally expects 12/min as the threshold for holding a routine
opioid dose.
Question 4 – Highlighting (Identify the findings that require
immediate follow-up)
Scenario: A nurse receives shift report on four clients. Click to highlight
the three findings that require immediate notification of the provider.
, Client A: Post-op day 1 after colectomy, temperature 38.1°C (100.6°F), HR
92, BP 118/76
Client B: Received insulin lispro at 07:30, now 09:00, blood glucose 55
mg/dL, diaphoretic, confused
Client C: Chronic kidney disease, potassium 5.9 mEq/L, no ECG changes
Client D: Hip replacement, reports incisional pain 5/10, morphine given 30
minutes ago
Highlighted answers: Client B (hypoglycemia with neuro symptoms),
Client C (potassium 5.9 – hyperkalemia risk), Client A (low-grade fever may
be expected, but post-op fever could indicate infection; however, among
options, B and C are most urgent, but question asks for three, so including
A is plausible in some contexts – but rational answer: B, C, and D? Actually
D is pain controlled. Let’s adjust: The three most urgent are B, C, and A?
No – on NCLEX, hypoglycemia and hyperkalemia are priorities. Third finding
could be fever if >38.3°C but this is 38.1. Let’s re-do with standard answer:
Correct highlights:
Client B (hypoglycemia with confusion – emergency)
Client C (K+ 5.9 – risk of cardiac arrest)
Client A (38.1°C is mild; but in post-op, it could be early sepsis – many
NCLEX questions would include fever >38°C as urgent)
Better answer for exam purposes: Highlight B, C, and A because a new
fever post-colectomy requires evaluation for anastomotic leak or infection.
Rationale: Hypoglycemia with altered mental status needs immediate
dextrose; hyperkalemia >5.5 needs treatment; post-op fever >38°C requires
provider notification. Client D’s pain is expected and treated.
Question 5 – Drag and Drop (Ordering/Prioritizing)
