NCSBN NCLEX RN TEST BANK With And Answers
Actual Exam Newest Complete Questions And Correct
Detailed Answers With Rationales | Already Graded
A+
1. A patient with a history of chronic heart failure presents with acute dyspnea, pink frothy
sputum, and oxygen saturation of 88% on room air. Which intervention should the nurse
implement first?
A. Administer intravenous furosemide 40 mg
B. Place the patient in high Fowler's position
C. Apply non-rebreather mask at 15 L/min
D. Obtain a 12-lead electrocardiogram
Answer: B
Rationale: High Fowler's position reduces venous return and improves ventilation, providing immediate
relief. While oxygen and diuretics are critical, positioning is the quickest non-invasive action. ECG is
diagnostic but not the priority.
2. A nurse is assessing a patient who received a unit of packed red blood cells 30 minutes ago.
Which finding requires immediate action?
A. Blood pressure 100/60 mm Hg
B. Temperature 37.8°C (100°F)
C. Heart rate 88 beats per minute
D. Respiratory rate 16 breaths per minute
Answer: B
Rationale: A temperature rise of 1°C or more during transfusion may indicate a febrile non-hemolytic
reaction or acute hemolytic reaction, requiring immediate stop of transfusion. The other vital signs are
within normal limits.
3. A nurse is teaching a patient about the use of a metered-dose inhaler (MDI) with a spacer. Which
statement indicates the need for further instruction?
A. I will shake the inhaler before each use.
B. I will breathe out normally before placing the mouthpiece in my mouth.
C. I will hold my breath for 10 seconds after inhaling the medication.
D. I will inhale quickly and deeply after pressing the canister.
Answer: D
Rationale: The correct technique is to inhale slowly and deeply (over 3-5 seconds) after actuation to
allow optimal deposition. Rapid inhalation can cause oropharyngeal deposition. The other statements
are correct.
Page 1
,4. A patient with schizophrenia is prescribed clozapine. Which laboratory value must be monitored
before initiating therapy?
A. Serum potassium
B. Absolute neutrophil count
C. Hemoglobin A1c
D. Thyroid-stimulating hormone
Answer: B
Rationale: Clozapine carries a risk of agranulocytosis; baseline and weekly ANC monitoring is
mandatory. The other labs are not specific to clozapine's major adverse effect.
5. A patient in the emergency department has a pH of 7.28, PaCO2 55 mm Hg, HCO3- 24 mEq/L.
Which acid-base imbalance is present?
A. Metabolic acidosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis
Answer: B
Rationale: Low pH (acidosis) with elevated PaCO2 (respiratory cause) and normal HCO3- indicates
acute respiratory acidosis. The kidneys have not yet compensated.
6. A nurse is caring for a patient with acute pancreatitis. Which finding indicates a complication?
A. Serum amylase 300 units/L
B. Cullen sign
C. Nausea and vomiting
D. Epigastric pain radiating to the back
Answer: B
Rationale: Cullen sign (periumbilical ecchymosis) indicates retroperitoneal hemorrhage, a severe
complication of pancreatitis. Elevated amylase, nausea, and epigastric pain are expected findings.
7. A nurse is evaluating a patient's understanding of a low-sodium diet. Which meal selection
indicates the patient understands the teaching?
A. Grilled chicken breast with steamed rice and a side of canned green beans
B. Turkey sandwich on whole wheat bread with lettuce and tomato
C. Baked salmon with a baked potato and fresh asparagus
D. Cheeseburger with french fries and a pickle
Answer: C
Rationale: Fresh asparagus, baked potato, and baked salmon are naturally low in sodium. Canned green
beans (A) are high in sodium; turkey sandwich (B) may contain processed meats; cheeseburger (D) is
high in sodium.
Page 2
,8. A patient with deep vein thrombosis is receiving a continuous heparin infusion. The aPTT is 90
seconds (therapeutic range 60-80 seconds). What is the nurse's priority action?
A. Increase the infusion rate by 100 units/hour
B. Stop the infusion for 1 hour and notify the provider
C. Administer protamine sulfate immediately
D. Continue the infusion as prescribed
Answer: B
Rationale: An aPTT above therapeutic range increases bleeding risk; the infusion should be paused per
protocol and the provider notified for dose adjustment. Protamine is for severe bleeding, not routine
management.
9. A nurse is assessing a patient who has just undergone a thyroidectomy. Which finding requires
immediate intervention?
A. Hoarse voice
B. Serum calcium 7.8 mg/dL
C. Pain at the incision site rated 4/10
D. Serum potassium 4.2 mEq/L
Answer: B
Rationale: Hypocalcemia (normal 8.5-10.5 mg/dL) indicates possible parathyroid injury, leading to
tetany and laryngospasm. Hoarseness may be due to laryngeal nerve irritation but is not immediately
life-threatening.
10. A patient with a history of substance use disorder is admitted for detoxification. Which
assessment finding is most concerning during alcohol withdrawal?
A. Heart rate 100 beats per minute
B. Blood pressure 140/90 mm Hg
C. Tremors in both hands
D. Disorientation to person, place, and time
Answer: D
Rationale: Disorientation indicates delirium tremens, a medical emergency with high mortality.
Tachycardia, hypertension, and tremors are common withdrawal symptoms but less immediately
dangerous.
11. A patient with a history of chronic kidney disease (stage 4) is admitted with hyperkalemia (K+
6.8 mEq/L) and ECG changes (peaked T waves). The nurse reviews the provider's prescriptions.
Which of the following prescriptions should the nurse question?
A. Administer intravenous calcium gluconate 10 mL of 10% solution over 2 minutes.
B. Administer regular insulin 10 units IV push followed by 50 mL of 50% dextrose IV.
C. Administer sodium polystyrene sulfonate (Kayexalate) 30 g orally.
D. Administer albuterol 10 mg via nebulization.
Answer: C
Rationale: Sodium polystyrene sulfonate (Kayexalate) is contraindicated in patients with chronic kidney
disease due to risk of intestinal necrosis, especially in those with impaired bowel function or after
Page 3
, surgery. Additionally, it has a delayed onset and is not first-line for acute hyperkalemia. Calcium
gluconate stabilizes the cardiac membrane, insulin/dextrose shifts potassium intracellularly, and
albuterol also promotes intracellular shift; these are appropriate acute interventions.
12. A nurse is caring for a patient with a chest tube connected to a water seal drainage system. The
patient is repositioned, and the nurse notices continuous bubbling in the water seal chamber. The
patient reports no dyspnea, and vital signs are stable. What is the nurse's priority action?
A. Clamp the chest tube immediately and notify the provider.
B. Check the drainage system for air leaks and tighten all connections.
C. Increase the suction pressure to eliminate the bubbling.
D. Document the finding and continue to monitor.
Answer: B
Rationale: Continuous bubbling in the water seal chamber indicates an air leak, which is abnormal
(intermittent bubbling is expected during exhalation/coughing). The priority is to locate and correct the
leak, typically by checking connections. Clamping is dangerous as it could cause tension pneumothorax.
Increasing suction is not indicated. Documentation is appropriate after assessment and intervention.
13. A nurse is assessing a patient with suspected compartment syndrome of the lower leg following
a tibial fracture. Which assessment finding is most indicative of compartment syndrome and
requires immediate intervention?
A. Pain that is out of proportion to the injury and worsens with passive stretch.
B. Visible deformity and swelling of the affected limb.
C. Paresthesia and pallor distal to the injury.
D. Capillary refill less than 2 seconds.
Answer: A
Rationale: Compartment syndrome is characterized by severe pain that is disproportionate to the injury
and exacerbated by passive stretching of the muscles. This is an early and critical sign. While
paresthesia, pallor, and pulselessness are later signs, they indicate advanced ischemia. Deformity and
swelling are common with fractures but not specific. Capillary refill <2 seconds is normal.
14. A patient with type 1 diabetes mellitus is admitted with diabetic ketoacidosis (DKA). The nurse
initiates an insulin infusion at 0.1 units/kg/hour. Which laboratory value requires the most
immediate attention during treatment?
A. Serum potassium level of 3.2 mEq/L.
B. Serum glucose level of 450 mg/dL.
C. Serum bicarbonate level of 14 mEq/L.
D. Arterial pH of 7.20.
Answer: A
Rationale: Hypokalemia (K+ 3.2) is life-threatening because insulin therapy shifts potassium into cells,
worsening hypokalemia and risking cardiac arrhythmias. Potassium replacement must be initiated
before or concurrently with insulin when K+ is low. Hyperglycemia (450 mg/dL) is expected in DKA and
will be corrected with insulin. Bicarbonate and pH are monitored but not as immediately critical as
potassium.
Page 4
Actual Exam Newest Complete Questions And Correct
Detailed Answers With Rationales | Already Graded
A+
1. A patient with a history of chronic heart failure presents with acute dyspnea, pink frothy
sputum, and oxygen saturation of 88% on room air. Which intervention should the nurse
implement first?
A. Administer intravenous furosemide 40 mg
B. Place the patient in high Fowler's position
C. Apply non-rebreather mask at 15 L/min
D. Obtain a 12-lead electrocardiogram
Answer: B
Rationale: High Fowler's position reduces venous return and improves ventilation, providing immediate
relief. While oxygen and diuretics are critical, positioning is the quickest non-invasive action. ECG is
diagnostic but not the priority.
2. A nurse is assessing a patient who received a unit of packed red blood cells 30 minutes ago.
Which finding requires immediate action?
A. Blood pressure 100/60 mm Hg
B. Temperature 37.8°C (100°F)
C. Heart rate 88 beats per minute
D. Respiratory rate 16 breaths per minute
Answer: B
Rationale: A temperature rise of 1°C or more during transfusion may indicate a febrile non-hemolytic
reaction or acute hemolytic reaction, requiring immediate stop of transfusion. The other vital signs are
within normal limits.
3. A nurse is teaching a patient about the use of a metered-dose inhaler (MDI) with a spacer. Which
statement indicates the need for further instruction?
A. I will shake the inhaler before each use.
B. I will breathe out normally before placing the mouthpiece in my mouth.
C. I will hold my breath for 10 seconds after inhaling the medication.
D. I will inhale quickly and deeply after pressing the canister.
Answer: D
Rationale: The correct technique is to inhale slowly and deeply (over 3-5 seconds) after actuation to
allow optimal deposition. Rapid inhalation can cause oropharyngeal deposition. The other statements
are correct.
Page 1
,4. A patient with schizophrenia is prescribed clozapine. Which laboratory value must be monitored
before initiating therapy?
A. Serum potassium
B. Absolute neutrophil count
C. Hemoglobin A1c
D. Thyroid-stimulating hormone
Answer: B
Rationale: Clozapine carries a risk of agranulocytosis; baseline and weekly ANC monitoring is
mandatory. The other labs are not specific to clozapine's major adverse effect.
5. A patient in the emergency department has a pH of 7.28, PaCO2 55 mm Hg, HCO3- 24 mEq/L.
Which acid-base imbalance is present?
A. Metabolic acidosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis
Answer: B
Rationale: Low pH (acidosis) with elevated PaCO2 (respiratory cause) and normal HCO3- indicates
acute respiratory acidosis. The kidneys have not yet compensated.
6. A nurse is caring for a patient with acute pancreatitis. Which finding indicates a complication?
A. Serum amylase 300 units/L
B. Cullen sign
C. Nausea and vomiting
D. Epigastric pain radiating to the back
Answer: B
Rationale: Cullen sign (periumbilical ecchymosis) indicates retroperitoneal hemorrhage, a severe
complication of pancreatitis. Elevated amylase, nausea, and epigastric pain are expected findings.
7. A nurse is evaluating a patient's understanding of a low-sodium diet. Which meal selection
indicates the patient understands the teaching?
A. Grilled chicken breast with steamed rice and a side of canned green beans
B. Turkey sandwich on whole wheat bread with lettuce and tomato
C. Baked salmon with a baked potato and fresh asparagus
D. Cheeseburger with french fries and a pickle
Answer: C
Rationale: Fresh asparagus, baked potato, and baked salmon are naturally low in sodium. Canned green
beans (A) are high in sodium; turkey sandwich (B) may contain processed meats; cheeseburger (D) is
high in sodium.
Page 2
,8. A patient with deep vein thrombosis is receiving a continuous heparin infusion. The aPTT is 90
seconds (therapeutic range 60-80 seconds). What is the nurse's priority action?
A. Increase the infusion rate by 100 units/hour
B. Stop the infusion for 1 hour and notify the provider
C. Administer protamine sulfate immediately
D. Continue the infusion as prescribed
Answer: B
Rationale: An aPTT above therapeutic range increases bleeding risk; the infusion should be paused per
protocol and the provider notified for dose adjustment. Protamine is for severe bleeding, not routine
management.
9. A nurse is assessing a patient who has just undergone a thyroidectomy. Which finding requires
immediate intervention?
A. Hoarse voice
B. Serum calcium 7.8 mg/dL
C. Pain at the incision site rated 4/10
D. Serum potassium 4.2 mEq/L
Answer: B
Rationale: Hypocalcemia (normal 8.5-10.5 mg/dL) indicates possible parathyroid injury, leading to
tetany and laryngospasm. Hoarseness may be due to laryngeal nerve irritation but is not immediately
life-threatening.
10. A patient with a history of substance use disorder is admitted for detoxification. Which
assessment finding is most concerning during alcohol withdrawal?
A. Heart rate 100 beats per minute
B. Blood pressure 140/90 mm Hg
C. Tremors in both hands
D. Disorientation to person, place, and time
Answer: D
Rationale: Disorientation indicates delirium tremens, a medical emergency with high mortality.
Tachycardia, hypertension, and tremors are common withdrawal symptoms but less immediately
dangerous.
11. A patient with a history of chronic kidney disease (stage 4) is admitted with hyperkalemia (K+
6.8 mEq/L) and ECG changes (peaked T waves). The nurse reviews the provider's prescriptions.
Which of the following prescriptions should the nurse question?
A. Administer intravenous calcium gluconate 10 mL of 10% solution over 2 minutes.
B. Administer regular insulin 10 units IV push followed by 50 mL of 50% dextrose IV.
C. Administer sodium polystyrene sulfonate (Kayexalate) 30 g orally.
D. Administer albuterol 10 mg via nebulization.
Answer: C
Rationale: Sodium polystyrene sulfonate (Kayexalate) is contraindicated in patients with chronic kidney
disease due to risk of intestinal necrosis, especially in those with impaired bowel function or after
Page 3
, surgery. Additionally, it has a delayed onset and is not first-line for acute hyperkalemia. Calcium
gluconate stabilizes the cardiac membrane, insulin/dextrose shifts potassium intracellularly, and
albuterol also promotes intracellular shift; these are appropriate acute interventions.
12. A nurse is caring for a patient with a chest tube connected to a water seal drainage system. The
patient is repositioned, and the nurse notices continuous bubbling in the water seal chamber. The
patient reports no dyspnea, and vital signs are stable. What is the nurse's priority action?
A. Clamp the chest tube immediately and notify the provider.
B. Check the drainage system for air leaks and tighten all connections.
C. Increase the suction pressure to eliminate the bubbling.
D. Document the finding and continue to monitor.
Answer: B
Rationale: Continuous bubbling in the water seal chamber indicates an air leak, which is abnormal
(intermittent bubbling is expected during exhalation/coughing). The priority is to locate and correct the
leak, typically by checking connections. Clamping is dangerous as it could cause tension pneumothorax.
Increasing suction is not indicated. Documentation is appropriate after assessment and intervention.
13. A nurse is assessing a patient with suspected compartment syndrome of the lower leg following
a tibial fracture. Which assessment finding is most indicative of compartment syndrome and
requires immediate intervention?
A. Pain that is out of proportion to the injury and worsens with passive stretch.
B. Visible deformity and swelling of the affected limb.
C. Paresthesia and pallor distal to the injury.
D. Capillary refill less than 2 seconds.
Answer: A
Rationale: Compartment syndrome is characterized by severe pain that is disproportionate to the injury
and exacerbated by passive stretching of the muscles. This is an early and critical sign. While
paresthesia, pallor, and pulselessness are later signs, they indicate advanced ischemia. Deformity and
swelling are common with fractures but not specific. Capillary refill <2 seconds is normal.
14. A patient with type 1 diabetes mellitus is admitted with diabetic ketoacidosis (DKA). The nurse
initiates an insulin infusion at 0.1 units/kg/hour. Which laboratory value requires the most
immediate attention during treatment?
A. Serum potassium level of 3.2 mEq/L.
B. Serum glucose level of 450 mg/dL.
C. Serum bicarbonate level of 14 mEq/L.
D. Arterial pH of 7.20.
Answer: A
Rationale: Hypokalemia (K+ 3.2) is life-threatening because insulin therapy shifts potassium into cells,
worsening hypokalemia and risking cardiac arrhythmias. Potassium replacement must be initiated
before or concurrently with insulin when K+ is low. Hyperglycemia (450 mg/dL) is expected in DKA and
will be corrected with insulin. Bicarbonate and pH are monitored but not as immediately critical as
potassium.
Page 4
