NCLEX-RN National nursing licensure
examination evaluating clinical judgment, patient
safety, pharmacology knowledge, care planning,
and professional competence
Question 1
A nurse is caring for a patient with heart failure who reports sudden onset of
dyspnea and cough with frothy pink sputum. Which action should the nurse take
FIRST?
A) Administer furosemide IV push
B) Place the patient in high-Fowler’s position
C) Apply a non-rebreather mask at 15 L/min
D) Prepare for endotracheal intubation
Answer: B – Rationale: High-Fowler’s position reduces preload and improves
ventilation, which is immediate and non-invasive. Oxygen and furosemide follow,
but positioning is first.
Question 2
A patient is receiving IV heparin for a deep vein thrombosis. Which laboratory
value requires the nurse to notify the provider immediately?
A) aPTT 65 seconds (therapeutic range 60-80)
B) Platelet count 40,000/mm³
C) INR 1.2
D) Hemoglobin 12 g/dL
Answer: B – Rationale: Platelet count <50,000 or a drop >50% from baseline
suggests heparin-induced thrombocytopenia (HIT), a life-threatening
prothrombotic state. Heparin must be stopped immediately.
Question 3
,A patient with type 1 diabetes mellitus is found unresponsive, with cool clammy
skin and a blood glucose of 42 mg/dL. After administering 15 g of carbohydrate,
the patient does not improve. Which action should the nurse take next?
A) Repeat blood glucose in 15 minutes
B) Administer 1 mg of glucagon IM
C) Start an IV of D50W
D) Give 4 oz of orange juice
Answer: B – Rationale: The patient is unconscious and cannot swallow safely.
Glucagon (IM or subcutaneous) raises blood glucose by stimulating hepatic
glycogenolysis. IV dextrose is also acceptable but requires IV access; glucagon
can be given immediately.
Question 4
A nurse is assessing a patient with a chest tube to water seal drainage. Which
finding indicates a tension pneumothorax?
A) Continuous bubbling in the water seal chamber
B) Oscillations in the water seal with inspiration
C) Sudden tracheal deviation to the contralateral side with hypotension
D) Gentle bubbling in the suction chamber
Answer: C – Rationale: Tension pneumothorax presents with tracheal deviation
away from the affected side, absent breath sounds, hypotension, and distended
neck veins. This is a medical emergency.
Question 5
A patient with chronic kidney disease (stage 4) has a serum potassium of 6.8
mEq/L, peaked T waves, and a widened QRS. Which medication should the nurse
administer FIRST?
A) Sodium polystyrene sulfonate orally
B) Calcium gluconate IV
C) Insulin and dextrose IV
D) Albuterol nebulizer
,Answer: B – Rationale: Calcium gluconate stabilizes the cardiac membrane
immediately, reducing the risk of ventricular fibrillation. Insulin/glucose and
albuterol shift K⁺ into cells but take longer.
Question 6
A nurse is teaching a patient with a new prescription for warfarin. Which statement
by the patient indicates a need for further teaching?
A) “I will avoid eating large amounts of spinach and kale.”
B) “I will take ibuprofen for my occasional headaches.”
C) “I will get my INR checked regularly.”
D) “I will report any unusual bleeding or bruising.”
Answer: B – Rationale: Ibuprofen (NSAID) increases bleeding risk and can cause
gastrointestinal bleeding. Acetaminophen is preferred for pain relief in patients on
warfarin.
Question 7
A postoperative patient develops sudden chest pain, dyspnea, and hypotension. The
nurse notes a new oxygen requirement of 6 L/min to maintain SpO₂ 90%. Which
action takes priority?
A) Obtain a stat 12-lead ECG
B) Administer heparin IV bolus
C) Position the patient supine
D) Notify the rapid response team
Answer: D – Rationale: The patient is unstable (hypotension + hypoxia). The
rapid response team or provider should be notified immediately. Massive
pulmonary embolism is suspected; thrombolytics or embolectomy may be needed.
Question 8
A patient with cirrhosis has an INR of 3.5 and a platelet count of 50,000/mm³. The
nurse prioritizes which intervention?
A) Administer vitamin K orally
B) Prepare for platelet transfusion
, C) Implement bleeding precautions
D) Increase protein intake
Answer: C – Rationale: Bleeding precautions (soft toothbrush, avoid injections,
fall prevention) are the immediate priority because the patient is at high risk for
spontaneous bleeding due to coagulopathy and thrombocytopenia.
Question 9
A nurse is caring for a patient with a central line who develops fever, chills, and
hypotension. Which action should the nurse take FIRST?
A) Administer broad-spectrum antibiotics
B) Obtain blood cultures from the central line and a peripheral vein
C) Remove the central line immediately
D) Infuse normal saline bolus
Answer: B – Rationale: Before starting antibiotics, two sets of blood cultures (one
from the line, one peripherally) are needed to identify the pathogen and
differentiate line-related from systemic infection.
Question 10
A patient with preeclampsia is receiving IV magnesium sulfate. Which assessment
finding indicates magnesium toxicity?
A) Deep tendon reflexes 2+
B) Urine output 45 mL/hr
C) Respiratory rate 10 breaths/min
D) Serum magnesium level 5 mg/dL
Answer: C – *Rationale: Respiratory depression (<12/min) is a sign of magnesium
toxicity. Antidote is calcium gluconate. Normal reflexes (2+) and urine output >30
mL/hr are desired.*
Question 11
A nurse is planning care for a patient with a nasogastric tube to low intermittent
suction. Which electrolyte imbalance is the patient at highest risk for?
examination evaluating clinical judgment, patient
safety, pharmacology knowledge, care planning,
and professional competence
Question 1
A nurse is caring for a patient with heart failure who reports sudden onset of
dyspnea and cough with frothy pink sputum. Which action should the nurse take
FIRST?
A) Administer furosemide IV push
B) Place the patient in high-Fowler’s position
C) Apply a non-rebreather mask at 15 L/min
D) Prepare for endotracheal intubation
Answer: B – Rationale: High-Fowler’s position reduces preload and improves
ventilation, which is immediate and non-invasive. Oxygen and furosemide follow,
but positioning is first.
Question 2
A patient is receiving IV heparin for a deep vein thrombosis. Which laboratory
value requires the nurse to notify the provider immediately?
A) aPTT 65 seconds (therapeutic range 60-80)
B) Platelet count 40,000/mm³
C) INR 1.2
D) Hemoglobin 12 g/dL
Answer: B – Rationale: Platelet count <50,000 or a drop >50% from baseline
suggests heparin-induced thrombocytopenia (HIT), a life-threatening
prothrombotic state. Heparin must be stopped immediately.
Question 3
,A patient with type 1 diabetes mellitus is found unresponsive, with cool clammy
skin and a blood glucose of 42 mg/dL. After administering 15 g of carbohydrate,
the patient does not improve. Which action should the nurse take next?
A) Repeat blood glucose in 15 minutes
B) Administer 1 mg of glucagon IM
C) Start an IV of D50W
D) Give 4 oz of orange juice
Answer: B – Rationale: The patient is unconscious and cannot swallow safely.
Glucagon (IM or subcutaneous) raises blood glucose by stimulating hepatic
glycogenolysis. IV dextrose is also acceptable but requires IV access; glucagon
can be given immediately.
Question 4
A nurse is assessing a patient with a chest tube to water seal drainage. Which
finding indicates a tension pneumothorax?
A) Continuous bubbling in the water seal chamber
B) Oscillations in the water seal with inspiration
C) Sudden tracheal deviation to the contralateral side with hypotension
D) Gentle bubbling in the suction chamber
Answer: C – Rationale: Tension pneumothorax presents with tracheal deviation
away from the affected side, absent breath sounds, hypotension, and distended
neck veins. This is a medical emergency.
Question 5
A patient with chronic kidney disease (stage 4) has a serum potassium of 6.8
mEq/L, peaked T waves, and a widened QRS. Which medication should the nurse
administer FIRST?
A) Sodium polystyrene sulfonate orally
B) Calcium gluconate IV
C) Insulin and dextrose IV
D) Albuterol nebulizer
,Answer: B – Rationale: Calcium gluconate stabilizes the cardiac membrane
immediately, reducing the risk of ventricular fibrillation. Insulin/glucose and
albuterol shift K⁺ into cells but take longer.
Question 6
A nurse is teaching a patient with a new prescription for warfarin. Which statement
by the patient indicates a need for further teaching?
A) “I will avoid eating large amounts of spinach and kale.”
B) “I will take ibuprofen for my occasional headaches.”
C) “I will get my INR checked regularly.”
D) “I will report any unusual bleeding or bruising.”
Answer: B – Rationale: Ibuprofen (NSAID) increases bleeding risk and can cause
gastrointestinal bleeding. Acetaminophen is preferred for pain relief in patients on
warfarin.
Question 7
A postoperative patient develops sudden chest pain, dyspnea, and hypotension. The
nurse notes a new oxygen requirement of 6 L/min to maintain SpO₂ 90%. Which
action takes priority?
A) Obtain a stat 12-lead ECG
B) Administer heparin IV bolus
C) Position the patient supine
D) Notify the rapid response team
Answer: D – Rationale: The patient is unstable (hypotension + hypoxia). The
rapid response team or provider should be notified immediately. Massive
pulmonary embolism is suspected; thrombolytics or embolectomy may be needed.
Question 8
A patient with cirrhosis has an INR of 3.5 and a platelet count of 50,000/mm³. The
nurse prioritizes which intervention?
A) Administer vitamin K orally
B) Prepare for platelet transfusion
, C) Implement bleeding precautions
D) Increase protein intake
Answer: C – Rationale: Bleeding precautions (soft toothbrush, avoid injections,
fall prevention) are the immediate priority because the patient is at high risk for
spontaneous bleeding due to coagulopathy and thrombocytopenia.
Question 9
A nurse is caring for a patient with a central line who develops fever, chills, and
hypotension. Which action should the nurse take FIRST?
A) Administer broad-spectrum antibiotics
B) Obtain blood cultures from the central line and a peripheral vein
C) Remove the central line immediately
D) Infuse normal saline bolus
Answer: B – Rationale: Before starting antibiotics, two sets of blood cultures (one
from the line, one peripherally) are needed to identify the pathogen and
differentiate line-related from systemic infection.
Question 10
A patient with preeclampsia is receiving IV magnesium sulfate. Which assessment
finding indicates magnesium toxicity?
A) Deep tendon reflexes 2+
B) Urine output 45 mL/hr
C) Respiratory rate 10 breaths/min
D) Serum magnesium level 5 mg/dL
Answer: C – *Rationale: Respiratory depression (<12/min) is a sign of magnesium
toxicity. Antidote is calcium gluconate. Normal reflexes (2+) and urine output >30
mL/hr are desired.*
Question 11
A nurse is planning care for a patient with a nasogastric tube to low intermittent
suction. Which electrolyte imbalance is the patient at highest risk for?
