Free NCLEX-RN and NCLEX-PN practice questions with full clinical explanations, 50 flashcards, and official study resources.
The NCLEX is the licensing examination that determines whether a candidate is safe to practise as a nurse. It is not a knowledge test — it is a clinical judgement test. Tour practice set is built around the NCSBN Clinical Judgment Measurement Model, which means questions are framed as patient scenarios that require you to recognise cues, analyse information, prioritise problems, select interventions, and evaluate outcomes. Every explanation is written to model the reasoning process, not just identify the correct answer.
South African nurses qualifying for work in the US, Canada, the UK, or Australia will encounter tour exam. The Next Generation NCLEX (NGN) format uses a range of question types beyond simple multiple choice — tour practice set covers the core knowledge tested across all question formats.
The NCLEX is the standard nursing licensure examination. The Next Generation NCLEX (NGN) format requires clinical reasoning, not just memorisation.
Think like a nurse: Use Maslow's Hierarchy (physiological first), ABCs (Airway, Breathing, Circulation), and Safety when prioritising. Always choose the most conservative nursing action.
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Question 01 of 20
Normal adult heart rate?
Explanation: Normal adult HR: 60-100 bpm. Bradycardia <60, Tachycardia >100.
Question 02 of 20
Priority assessment before giving morphine?
Explanation: Morphine depresses respiratory centre. RR <12/min is a contraindication.
Question 03 of 20
Five Rights do NOT include?
Explanation: Five Rights: Patient, Drug, Dose, Route, Time. Right Diagnosis is NOT included.
Explanation: Normal K+: 3.5-5.0 mEq/L. Hypokalaemia <3.5. Hyperkalaemia >5.0.
Q21
A patient is admitted with a blood sugar of 38 mg/dL. What is the nurse's priority action?
Explanation: Hypoglycaemia (< 70 mg/dL) is life-threatening. Treat immediately: 15g fast carbs. Recheck in 15 min. If still < 70: repeat. If unconscious: IV dextrose or glucagon IM. Document and notify after treatment.
Q22
Which patient should the nurse see FIRST?
Explanation: Respiratory depression (RR 8, SpO₂ 88%) is immediately life-threatening — ABC priority. Assess airway and breathing first. May need: stimulation, supplemental O₂, repositioning, reversal agent (naloxone if opioid OD). Others can wait.
Q23
A patient is receiving heparin IV. What lab value must the nurse monitor?
Explanation: Heparin is monitored by aPTT. Warfarin is monitored by INR/PT. Therapeutic heparin: aPTT 60-100 seconds. Check aPTT 6 hours after any rate change. Antidote: protamine sulfate. Risk: HIT (heparin-induced thrombocytopenia).
Q24
What are signs of digoxin toxicity?
Explanation: Digoxin toxicity: narrow therapeutic index (0.5-2.0 ng/mL). Signs: bradycardia (< 60 bpm hold dose), GI (nausea, vomiting, anorexia), neuro (confusion, visual halos). Risk factors: hypokalaemia. Antidote: Digibind (Digoxin Fab fragments).
Q25
A post-operative patient has not voided in 8 hours. What should the nurse do first?
Explanation: Assessment first. Bladder scan: > 300 mL = distension. Interventions: privacy, running water, warm perineal wash. If conservative measures fail: straight catheterisation. Only then consider Foley. Document output. Report if no void in 8 hours post-op.
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Q26
A patient has just returned from cardiac catheterisation via the right femoral artery. What is the nursing priority?
Explanation: Femoral artery access: risk of bleeding, haematoma, arterial spasm. Assess: groin site (bleeding), distal pulses (circulation), sensation, colour. Keep leg straight for 2-6 hours. Monitor vital signs. Sandbag may be used. Report: absent pulse, expanding haematoma, pallor.
Q27
What is the therapeutic lithium level?
Explanation: Therapeutic lithium: 0.5-1.5 mEq/L (acute mania: 1.0-1.5, maintenance: 0.6-1.2). Toxic > 1.5 mEq/L. Signs of toxicity: tremors, GI symptoms, ataxia, confusion. Severe toxicity (> 3.0): seizures, cardiac arrhythmias. Adequate hydration and Na⁺ intake essential.
Q28
A patient's potassium level is 2.8 mEq/L. What is the nurse's priority concern?
Explanation: Normal K⁺: 3.5-5.0 mEq/L. Hypokalaemia (< 3.5): priority concern is cardiac arrhythmias (PVCs, V-tach, V-fib). Other signs: muscle weakness, cramps, fatigue, flattened T waves on ECG. IV K⁺ replacement: never IV push, always diluted and slow.
Q29
Which finding indicates a complication following a blood transfusion?
Explanation: Haemolytic transfusion reaction (ABO incompatibility): most severe type. Signs: fever, chills, back/flank pain, haematuria (haemoglobin in urine), hypotension, anxiety. Action: STOP transfusion immediately, maintain IV access with saline, notify blood bank and physician.
Q30
A patient with COPD has an SpO₂ of 85%. The nurse prepares to administer oxygen. At what flow rate?
Explanation: COPD: hypoxic drive. High O₂ can suppress breathing stimulus → CO₂ retention. Start low: 1-2 L/min NC. Target SpO₂: 88-92%. Monitor for CO₂ retention (drowsiness, confusion, decreased RR). Not withhold O₂ if critically hypoxic — just use lowest effective dose.
Q31
What is the most important action before administering any medication?
Explanation: 5 Rights (or 6–8 Rights in some systems): Right Patient (2 identifiers), Right Drug (3 checks), Right Dose (calculate), Right Route, Right Time, Right Documentation. Two identifiers: name + DOB, or name + MRN. Never verify by room number alone.
Q32
A patient with a chest tube suddenly reports severe pain and the water seal chamber is bubbling continuously. What should the nurse do?
Explanation: Continuous bubbling in water seal = air leak. Check connections from chest to collection system. If connections tight: leak is from patient (expected with pneumothorax). Clamp tube briefly to locate leak. Tension pneumothorax (absent breath sounds, tracheal deviation, hypotension): emergency — never clamp.
Q33
A patient is ordered NPO for surgery. They ask if they can take their morning antihypertensive. What should the nurse do?
Explanation: NPO typically refers to food and non-essential liquids. Essential medications (antihypertensives, cardiac drugs, anticonvulsants) are often given with a small sip of water. Always verify with surgical team. Abrupt withdrawal of antihypertensives can cause rebound hypertension.
Q34
Which intervention is most important when a patient is placed in restraints?
Explanation: Restraint care: neurovascular checks every 15-30 minutes, release and reposition every 2 hours, provide ROM exercises, offer toileting, reassess need regularly. Restraints are last resort — require MD order, documentation of rationale and alternatives tried. Never tie to side rails.
Q35
A patient with an NG tube has an order for aspirin 325mg. How should the nurse administer it?
Explanation: NG tube medications: crush (if crushable), dissolve in 15-30mL water, give each medication separately, flush 15-30mL water before and after each medication. Check: can the tablet be crushed? (Never crush: extended-release, enteric-coated, sublingual). Aspirin can be crushed.
Q36
What laboratory value is most important to check before administering a blood transfusion?
Explanation: Type and crossmatch (T&C) ensures ABO/Rh compatibility. Transfuse ABO-compatible blood only. Before transfusion: check T&C report, verify patient ID (2 identifiers) against blood bag with 2 nurses, check expiry date, inspect bag. Baseline vital signs before starting.
Q37
What is the nursing action when a patient experiences a tonic-clonic seizure?
Explanation: Seizure care: safety (do not restrain, remove hazards, pad rails), do not put anything in mouth (no tongue depressors — tour fractures teeth and injures nurse), position on side (recovery position) to prevent aspiration, time seizure, O₂ and suction available, IV access, document.
Q38
A patient receiving IV vancomycin develops flushing, erythema, and pruritus on the face and neck. What is this?
Explanation: Red man syndrome: not an allergy (IgE-mediated), an infusion reaction to rapid vancomycin. Management: slow infusion rate (infuse over at least 60 minutes), pre-medicate with diphenhydramine if needed. If true allergy (anaphylaxis): stop drug, epinephrine, different antibiotic.
Q39
What are the early signs of increased intracranial pressure (ICP)?
Explanation: Early ICP signs: restlessness, headache, nausea, subtle LOC changes. Late signs (Cushing's triad): bradycardia, hypertension with widening pulse pressure, irregular respirations (Cheyne-Stokes). Interventions: HOB 30°, avoid Valsalva, avoid hip flexion, O₂, quiet environment.
Q40
What is the normal serum sodium level?
Explanation: Normal Na⁺: 135-145 mEq/L. Hyponatraemia (< 135): dilution (SIADH, water intoxication) or depletion (diarrhoea, diuretics). Signs: confusion, seizures. Hypernatraemia (> 145): water deficit or excess Na⁺. Signs: thirst, agitation, seizures.
Q41
A patient with a newly applied cast reports severe pain unrelieved by analgesics and paresthesia. What does tour indicate?
A patient is ordered NPH insulin 20 units and regular insulin 10 units mixed in the same syringe. What is drawn up first?
Explanation: 'Clear before cloudy': regular (clear) drawn first to prevent contamination of regular insulin vial with NPH (cloudy). If NPH enters regular vial, it changes regular insulin's action. Memory: Regular = clear, R-regular = R comes first.
Q43
What is a priority nursing concern for a patient with a new colostomy?
Explanation: Healthy stoma: pink/red, moist. Dark (blue-black): ischaemia. Pale: anaemia or ischaemia. Dusky: venous congestion. Report abnormal colour immediately. Also monitor: output (ileal stoma: liquid, colostomy: more formed), skin integrity around stoma, teaching patient ostomy care.
Q44
Which is the priority nursing action for a patient who pulls out their endotracheal tube?
Explanation: Self-extubation: maintain patent airway first. Manual ventilation with bag-valve-mask if needed. Call RRT/code if apnoea. Have suction, O₂, and intubation equipment ready. Assess respiratory status. Prevention: assess need for restraints, sedation titration, frequent assessment for extubation readiness.
Q45
What is the priority nursing assessment for a patient receiving total parenteral nutrition (TPN)?
Explanation: TPN complications: hyperglycaemia (most common — monitor glucose every 4-6 hours, give insulin as ordered), infection (central line — strict aseptic technique), rebound hypoglycaemia (if stopped suddenly — taper), fluid overload, electrolyte imbalances. Change tubing every 24 hours.
Q46
A patient with a suspected MI is prescribed aspirin 325mg. They say they are allergic to aspirin. What should the nurse do?
Explanation: Clarify allergy type before withholding critical medication. True aspirin allergy (anaphylaxis, urticaria): contraindicated — notify physician for alternative (clopidogrel). GI intolerance is not a true allergy — physician may still order given MI risk. Always document and communicate.
What is the difference between infiltration and extravasation of IV fluids?
Explanation: IV site complications: Infiltration: non-vesicant (saline, D5W) leaks → swelling, coolness, pain, slowed flow. Stop infusion, remove IV, apply warm compress. Extravasation: vesicant (chemo, phenytoin, dopamine) leaks → potential necrosis. Emergency: stop, aspirate, antidote per protocol, plastic surgery consult.
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Q51
A patient is admitted with a blood sugar of 38 mg/dL. What is the nurse's priority action?
Explanation: Hypoglycaemia (< 70 mg/dL) is life-threatening. Treat immediately: 15g fast carbs. Recheck in 15 min. If still < 70: repeat. If unconscious: IV dextrose or glucagon IM. Document and notify after treatment.
Q52
Which patient should the nurse see FIRST?
Explanation: Respiratory depression (RR 8, SpO₂ 88%) is immediately life-threatening — ABC priority. Assess airway and breathing first. May need: stimulation, supplemental O₂, repositioning, reversal agent (naloxone if opioid OD). Others can wait.
Q53
A patient is receiving heparin IV. What lab value must the nurse monitor?
Explanation: Heparin is monitored by aPTT. Warfarin is monitored by INR/PT. Therapeutic heparin: aPTT 60-100 seconds. Check aPTT 6 hours after any rate change. Antidote: protamine sulfate. Risk: HIT (heparin-induced thrombocytopenia).
Q54
What are signs of digoxin toxicity?
Explanation: Digoxin toxicity: narrow therapeutic index (0.5-2.0 ng/mL). Signs: bradycardia (< 60 bpm hold dose), GI (nausea, vomiting, anorexia), neuro (confusion, visual halos). Risk factors: hypokalaemia. Antidote: Digibind (Digoxin Fab fragments).
Q55
A post-operative patient has not voided in 8 hours. What should the nurse do first?
Explanation: Assessment first. Bladder scan: > 300 mL = distension. Interventions: privacy, running water, warm perineal wash. If conservative measures fail: straight catheterisation. Only then consider Foley. Document output. Report if no void in 8 hours post-op.
Q56
A patient has just returned from cardiac catheterisation via the right femoral artery. What is the nursing priority?
Explanation: Femoral artery access: risk of bleeding, haematoma, arterial spasm. Assess: groin site (bleeding), distal pulses (circulation), sensation, colour. Keep leg straight for 2-6 hours. Monitor vital signs. Sandbag may be used. Report: absent pulse, expanding haematoma, pallor.
Q57
What is the therapeutic lithium level?
Explanation: Therapeutic lithium: 0.5-1.5 mEq/L (acute mania: 1.0-1.5, maintenance: 0.6-1.2). Toxic > 1.5 mEq/L. Signs of toxicity: tremors, GI symptoms, ataxia, confusion. Severe toxicity (> 3.0): seizures, cardiac arrhythmias. Adequate hydration and Na⁺ intake essential.
Q58
A patient's potassium level is 2.8 mEq/L. What is the nurse's priority concern?
Explanation: Normal K⁺: 3.5-5.0 mEq/L. Hypokalaemia (< 3.5): priority concern is cardiac arrhythmias (PVCs, V-tach, V-fib). Other signs: muscle weakness, cramps, fatigue, flattened T waves on ECG. IV K⁺ replacement: never IV push, always diluted and slow.
Q59
Which finding indicates a complication following a blood transfusion?
Explanation: Haemolytic transfusion reaction (ABO incompatibility): most severe type. Signs: fever, chills, back/flank pain, haematuria (haemoglobin in urine), hypotension, anxiety. Action: STOP transfusion immediately, maintain IV access with saline, notify blood bank and physician.
Q60
A patient with COPD has an SpO₂ of 85%. The nurse prepares to administer oxygen. At what flow rate?
Explanation: COPD: hypoxic drive. High O₂ can suppress breathing stimulus → CO₂ retention. Start low: 1-2 L/min NC. Target SpO₂: 88-92%. Monitor for CO₂ retention (drowsiness, confusion, decreased RR). Not withhold O₂ if critically hypoxic — just use lowest effective dose.
Q61
What is the most important action before administering any medication?
Explanation: 5 Rights (or 6–8 Rights in some systems): Right Patient (2 identifiers), Right Drug (3 checks), Right Dose (calculate), Right Route, Right Time, Right Documentation. Two identifiers: name + DOB, or name + MRN. Never verify by room number alone.
Q62
A patient with a chest tube suddenly reports severe pain and the water seal chamber is bubbling continuously. What should the nurse do?
Explanation: Continuous bubbling in water seal = air leak. Check connections from chest to collection system. If connections tight: leak is from patient (expected with pneumothorax). Clamp tube briefly to locate leak. Tension pneumothorax (absent breath sounds, tracheal deviation, hypotension): emergency — never clamp.
Q63
A patient is ordered NPO for surgery. They ask if they can take their morning antihypertensive. What should the nurse do?
Explanation: NPO typically refers to food and non-essential liquids. Essential medications (antihypertensives, cardiac drugs, anticonvulsants) are often given with a small sip of water. Always verify with surgical team. Abrupt withdrawal of antihypertensives can cause rebound hypertension.
Q64
Which intervention is most important when a patient is placed in restraints?
Explanation: Restraint care: neurovascular checks every 15-30 minutes, release and reposition every 2 hours, provide ROM exercises, offer toileting, reassess need regularly. Restraints are last resort — require MD order, documentation of rationale and alternatives tried. Never tie to side rails.
Q65
A patient with an NG tube has an order for aspirin 325mg. How should the nurse administer it?
Explanation: NG tube medications: crush (if crushable), dissolve in 15-30mL water, give each medication separately, flush 15-30mL water before and after each medication. Check: can the tablet be crushed? (Never crush: extended-release, enteric-coated, sublingual). Aspirin can be crushed.
Q66
What laboratory value is most important to check before administering a blood transfusion?
Explanation: Type and crossmatch (T&C) ensures ABO/Rh compatibility. Transfuse ABO-compatible blood only. Before transfusion: check T&C report, verify patient ID (2 identifiers) against blood bag with 2 nurses, check expiry date, inspect bag. Baseline vital signs before starting.
Q67
What is the nursing action when a patient experiences a tonic-clonic seizure?
Explanation: Seizure care: safety (do not restrain, remove hazards, pad rails), do not put anything in mouth (no tongue depressors — tour fractures teeth and injures nurse), position on side (recovery position) to prevent aspiration, time seizure, O₂ and suction available, IV access, document.
Q68
A patient receiving IV vancomycin develops flushing, erythema, and pruritus on the face and neck. What is this?
Explanation: Red man syndrome: not an allergy (IgE-mediated), an infusion reaction to rapid vancomycin. Management: slow infusion rate (infuse over at least 60 minutes), pre-medicate with diphenhydramine if needed. If true allergy (anaphylaxis): stop drug, epinephrine, different antibiotic.
Q69
What are the early signs of increased intracranial pressure (ICP)?
Explanation: Early ICP signs: restlessness, headache, nausea, subtle LOC changes. Late signs (Cushing's triad): bradycardia, hypertension with widening pulse pressure, irregular respirations (Cheyne-Stokes). Interventions: HOB 30°, avoid Valsalva, avoid hip flexion, O₂, quiet environment.
Q70
What is the normal serum sodium level?
Explanation: Normal Na⁺: 135-145 mEq/L. Hyponatraemia (< 135): dilution (SIADH, water intoxication) or depletion (diarrhoea, diuretics). Signs: confusion, seizures. Hypernatraemia (> 145): water deficit or excess Na⁺. Signs: thirst, agitation, seizures.
Q71
A patient with a newly applied cast reports severe pain unrelieved by analgesics and paresthesia. What does tour indicate?
A patient is ordered NPH insulin 20 units and regular insulin 10 units mixed in the same syringe. What is drawn up first?
Explanation: 'Clear before cloudy': regular (clear) drawn first to prevent contamination of regular insulin vial with NPH (cloudy). If NPH enters regular vial, it changes regular insulin's action. Memory: Regular = clear, R-regular = R comes first.
Q73
What is a priority nursing concern for a patient with a new colostomy?
Explanation: Healthy stoma: pink/red, moist. Dark (blue-black): ischaemia. Pale: anaemia or ischaemia. Dusky: venous congestion. Report abnormal colour immediately. Also monitor: output (ileal stoma: liquid, colostomy: more formed), skin integrity around stoma, teaching patient ostomy care.
Q74
Which is the priority nursing action for a patient who pulls out their endotracheal tube?
Explanation: Self-extubation: maintain patent airway first. Manual ventilation with bag-valve-mask if needed. Call RRT/code if apnoea. Have suction, O₂, and intubation equipment ready. Assess respiratory status. Prevention: assess need for restraints, sedation titration, frequent assessment for extubation readiness.
Q75
What is the priority nursing assessment for a patient receiving total parenteral nutrition (TPN)?
Explanation: TPN complications: hyperglycaemia (most common — monitor glucose every 4-6 hours, give insulin as ordered), infection (central line — strict aseptic technique), rebound hypoglycaemia (if stopped suddenly — taper), fluid overload, electrolyte imbalances. Change tubing every 24 hours.
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Q76
A patient with a suspected MI is prescribed aspirin 325mg. They say they are allergic to aspirin. What should the nurse do?
Explanation: Clarify allergy type before withholding critical medication. True aspirin allergy (anaphylaxis, urticaria): contraindicated — notify physician for alternative (clopidogrel). GI intolerance is not a true allergy — physician may still order given MI risk. Always document and communicate.
What is the difference between infiltration and extravasation of IV fluids?
Explanation: IV site complications: Infiltration: non-vesicant (saline, D5W) leaks → swelling, coolness, pain, slowed flow. Stop infusion, remove IV, apply warm compress. Extravasation: vesicant (chemo, phenytoin, dopamine) leaks → potential necrosis. Emergency: stop, aspirate, antidote per protocol, plastic surgery consult.
Q81
A patient taking warfarin reports eating large amounts of green leafy vegetables daily. What is the concern?
Explanation: Warfarin and Vitamin K: Vitamin K is the antidote to warfarin. Inconsistent intake causes fluctuating INR. Educate: consistent (not zero) vitamin K intake. Monitor INR regularly. Significant interactions: many antibiotics (decrease gut flora that make Vit K), NSAIDs (increase bleeding risk), aspirin.
Q82
A patient with heart failure is prescribed furosemide. What electrolyte must be monitored closely?
Explanation: Furosemide (Lasix): loop diuretic — blocks Na/K/Cl transport in loop of Henle. Causes potassium loss → hypokalaemia → cardiac arrhythmia risk. Monitor K⁺ before each dose. Give with food. Potassium supplementation often needed. Check digoxin level if patient is on both (hypokalaemia increases digoxin toxicity risk).
Q83
What is the correct position for a patient in hypovolemic shock?
Explanation: Hypovolemic shock: priority = increase perfusion to vital organs. Elevate legs (passive leg raise) → increases venous return. Flat position. High Fowler's used for respiratory distress. Left lateral for: birthing (relieve aortocaval compression), liver biopsy, left-sided cardiac procedures. Prone: ARDS (improves oxygenation).
Q84
A patient's NG tube feeding is running. They vomit and appear distressed. What should the nurse do first?
Explanation: Vomiting with NG feeding: aspiration risk is immediate concern. Stop feeding → prevent more from running. Side position → drainage, not aspiration. Suction if needed. Assess: breath sounds (aspiration signs), oxygen saturation. Check residual before next feeding. Report to physician.
Q85
A post-operative patient has a urine output of 20 mL over the last hour. What action does the nurse take first?
Explanation: Oliguria (< 30 mL/hr): assess first. Check: catheter patency (kinked, clamped), blood pressure, fluid balance, pain (can cause urinary retention). Pre-renal (dehydration): fluid challenge may be ordered. Intrinsic renal: investigate cause. Post-renal: relieve obstruction. Notify physician after assessment.
Q86
A patient is prescribed metformin for type 2 diabetes. What is the most important teaching point?
Explanation: Metformin and contrast: IV iodinated contrast can temporarily impair renal function → metformin accumulates → lactic acidosis (rare but serious). Standard practice: hold metformin at time of procedure, restart 48 hours later if creatinine is normal. Metformin first-line for T2DM. Does not cause hypoglycaemia alone.
Q87
A patient newly diagnosed with tuberculosis is placed in a room. What type of precautions are required?
Explanation: TB airborne precautions: N-95 respirator for all who enter room (not just surgical mask). Negative pressure room (air flows in, not out). Door kept closed. Patient: surgical mask when outside room. Treatment: minimum 6 months of RIPE therapy (Rifampin, Isoniazid, Pyrazinamide, Ethambutol). Directly observed therapy (DOT) recommended.
Q88
A patient with chronic kidney disease has a potassium level of 5.8 mEq/L. Which food should the nurse advise the patient to avoid?
Explanation: Hyperkalaemia diet in CKD: avoid high-K foods: bananas, oranges, potatoes, tomatoes, legumes, nuts, avocado, dairy. Choose: apples, berries, white rice, pasta, white bread. Cooking method: leaching vegetables (peeling, cutting small, boiling in large water, discarding water) reduces potassium content.
Q89
A nurse prepares to administer a blood transfusion. The patient develops fever and chills 20 minutes in. What is the first action?
Explanation: Transfusion reaction protocol: STOP immediately. Maintain IV with NS (don't disconnect). Assess: vital signs, urine colour (haematuria = haemolytic reaction). Notify physician and blood bank. Send: blood bag, tubing, and patient blood/urine samples to lab. Fever alone may be febrile non-haemolytic reaction (most common) but cannot exclude haemolytic reaction.
Q90
A patient with asthma has an SpO₂ of 91% and audible wheezing. What is the priority intervention?
Explanation: Asthma acute episode: short-acting beta-2 agonist (salbutamol) first — bronchodilator for immediate relief. Then assess response. If no improvement: ipratropium (anticholinergic), systemic corticosteroids (reduce inflammation), supplemental O₂. Severe: IV magnesium sulphate, IV salbutamol, consider intubation. Measure peak flow before and after.
Q91
A patient has a nasogastric tube. Before each feeding, the nurse checks residual volume. At what volume should feeding be held?
Explanation: Gastric residual volume (GRV): evidence base for holding feeds is debated. Most facilities: hold if GRV > 250-500 mL and reassess in 1-2 hours. Return aspirate to patient (prevents electrolyte loss). A single high GRV should not automatically stop feeds. Assess: bowel sounds, abdominal distension, nausea. Feeds held without reason can cause malnutrition.
Q92
A patient with MRSA wound is admitted. A second patient is placed in the same room. Which action is appropriate?
Explanation: MRSA: contact precautions required. Private room preferred. Cohorting (same organism together) acceptable if private room unavailable. Gown and gloves upon entry. Dedicated equipment (stethoscope, BP cuff). Hand hygiene critical: soap and water if C. diff (alcohol not effective for C. diff spores).
Q93
A patient tells the nurse they have decided to refuse a recommended surgery. What is the nurse's appropriate response?
Explanation: Informed refusal: patient has right to refuse any treatment (autonomy). Nurse role: assess understanding, ensure information was complete and comprehended, document patient statement, notify physician, continue all other care. Never coerce. May need ethics consultation for complex cases. Document using patient's own words.
Q94
A patient receiving IV heparin has an aPTT of 150 seconds. What action should the nurse take?
Explanation: aPTT monitoring with heparin: therapeutic range 60-100s (1.5-2.5× normal of ~35-45s). aPTT 150s is dangerously high → bleeding risk. Action: hold infusion, notify physician, monitor for bleeding signs (haematuria, haematemesis, altered mental status). Antidote if severe: protamine sulphate. Adjust infusion rate per protocol.
Q95
A nurse is caring for a patient who has just been told they have terminal cancer. The patient says 'I don't want to talk about it.' What is the best response?
Explanation: Therapeutic communication with denial/shock: respect patient's need to process. Don't force discussion. Stay present: 'I'm here when you're ready.' Denial is a normal grief response (Kübler-Ross stages: denial, anger, bargaining, depression, acceptance). Return later. Offer presence and support without pressure.
Q96
A nurse hears a patient call out for help. Entering the room, the nurse finds the patient on the floor. What is the first action?
Explanation: Fall response: assess first. Check: level of consciousness, pain, obvious injuries, vital signs. Don't move if spinal injury possible. Call for help. After assessment: move safely with assistance. Document: what patient says, where found, apparent injuries, nurse's assessment. Incident report: risk management tool, not in medical record.
Q97
A patient with a hip replacement asks if they can cross their legs. What is the correct response?
Explanation: Hip replacement precautions (posterior approach): do not: flex hip >90°, cross legs (adduction), rotate foot inward (internal rotation). Do: use elevated toilet seat, avoid low chairs, sleep with pillow between legs. These prevent prosthesis dislocation. Duration varies by approach and surgeon preference.
Q98
A patient is receiving a continuous IV infusion and the site becomes swollen, pale, and cool. What is this?
Explanation: Infiltration: signs — swelling, pallor, coolness, slower flow, pain. Stop infusion immediately. Remove catheter. Elevate limb. Warm compress for non-vesicant (increases reabsorption). Restart in opposite extremity. Document. Extravasation: same signs but vesicant fluid — can cause necrosis. Emergency intervention required.
Q99
A nurse is about to administer insulin when the patient's tray arrives. The patient has type 1 diabetes. What is the correct sequence?
Explanation: Rapid-acting insulin timing: inject when meal is present (to prevent hypoglycaemia if patient doesn't eat). Patient must eat within 15 minutes. NPH: give 30-60 min before eating. Long-acting (glargine): any time, consistent daily time. If patient refuses meal after rapid insulin: give 15g fast-acting carbohydrate immediately.
Q100
What is the priority assessment for a patient who has just had a lumbar puncture?
A patient is prescribed oral vancomycin for C. difficile. What route should the nurse use?
Explanation: C. diff treatment: oral vancomycin or fidaxomicin (first-line). Oral: acts in gut, not absorbed. IV vancomycin: does not reach gut lumen in therapeutic levels — ineffective for C. diff. Metronidazole: no longer first-line (high recurrence). Bezlotoxumab: monoclonal antibody to prevent recurrence. Contact precautions + soap and water handwashing (alcohol doesn't kill spores).
Q102
A patient taking lithium complains of coarse tremors, confusion, and vomiting. What does the nurse suspect?
Explanation: Lithium toxicity levels: therapeutic 0.5-1.5. Mild toxicity 1.5-2.0: fine tremor, GI symptoms. Moderate 2.0-2.5: coarse tremor, confusion, ataxia. Severe > 2.5: seizures, arrhythmias, coma. Treatment: hold lithium, IV fluids (Na+ helps excretion), haemodialysis if severe. Dehydration, NSAIDs, and low-sodium diet increase lithium levels.
Q103
A nurse notes a patient's urine is dark amber and concentrated. What is the most likely interpretation?
Explanation: Urine assessment: pale yellow = well hydrated. Dark amber = dehydrated or concentrated. Orange = possible bilirubin, rifampin, carrot excess. Red/pink = blood (haematuria), beetroot, menstruation. Cloudy = possible infection (but UTI needs UA confirmation). Nurses: measure and document all output, report < 30 mL/hr.
Q104
A patient undergoing chemotherapy has a neutrophil count of 450/mm³. What is the priority nursing concern?
Explanation: Neutropenic precautions: ANC < 1000: neutropenia. < 500: severe. < 100: profound. Febrile neutropenia: temperature ≥ 38.3°C + ANC < 500 = medical emergency (sepsis risk). Protocol: blood cultures, broad-spectrum antibiotics within 1 hour. Nurse: avoid fresh flowers/plants, raw food, crowds, sick visitors; monitor temperature every 4 hours.
Q105
A nurse finds a patient attempting to remove their endotracheal tube while on a ventilator. What is the first action?
Explanation: Self-extubation prevention: maintain tube position first (hold tube manually), call for help immediately, assess why patient is agitated (pain, too awake, inadequate sedation, hypoxia), notify physician/RT. If successful self-extubation: assess airway, prepare for re-intubation, bag-valve-mask if apnoeic. Prevent future: reassess sedation and agitation management.
Q106
A patient with peripheral vascular disease reports leg pain at rest that worsens when elevated. Tour suggests?
Explanation: Arterial vs venous: Arterial (PAD): pale/mottled skin, weak/absent pulses, cool, hairless, thin skin, pain with elevation/exercise (intermittent claudication), ulcers on toes/pressure points. Venous: brown pigmentation, oedema, varicosities, ulcers on medial ankle, pain improves with elevation. Assessment: ankle-brachial index (ABI) for arterial.
Q107
What is informed consent?
Explanation: Informed consent requirements: disclosure (information), comprehension (understanding), voluntariness (no coercion), competence (capacity), consent (decision). Nurse role: witness signature, ensure patient understood, notify physician if patient has questions/concerns. Nurse does NOT obtain informed consent for invasive procedures (physician responsibility). Emergency: implied consent if patient unconscious and no surrogate.
Q108
A patient is ordered IV morphine for post-operative pain. Before administering, what must the nurse assess?
A patient's IV site shows redness, warmth, pain, and a palpable cord along the vein. Tour is?
Explanation: Phlebitis: remove IV catheter. Apply warm compress. Restart IV proximally or opposite extremity. Grade 0-4: Grade 1 (pain at site), Grade 2 (+redness/oedema), Grade 3 (+streak/palpable cord), Grade 4 (+pus, > 2.5 cm cord). Prevention: smallest gauge, appropriate dressing, stabilise catheter, use central line for irritating medications.
Q110
A patient is in respiratory distress. Priority interventions in correct order?
Explanation: Respiratory distress priority: A (airway: is it patent?), B (breathing: rate, depth, effort, O₂ sat), C (circulation). Interventions: position (high Fowler's), supplemental O₂, call for help, assess cause (bronchospasm → bronchodilator; fluid overload → diuretics; anxiety → calm environment). Never leave patient alone.
Q111
A patient newly started on an SSRI for depression says they feel worse after 2 weeks. What is the appropriate response?
Explanation: SSRI timeline: antidepressant effect: 2-6 weeks for full response. Early: increased energy, sleep improvement. Paradox: increased energy before mood improvement → may increase suicidal risk early in treatment. Monitor closely first 4 weeks. Black box warning: increased suicidality in under 24s. Educate patient not to stop abruptly (discontinuation syndrome).
Question 112 of 150
A patient is admitted with a blood sugar of 38 mg/dL. What is the nurse's priority action?
Explanation: Hypoglycaemia (< 70 mg/dL) is life-threatening. Treat immediately: 15g fast carbs. Recheck in 15 min. If still < 70: repeat. If unconscious: IV dextrose or glucagon IM. Document and notify after treatment.
Question 113 of 150
Which patient should the nurse see FIRST?
Explanation: Respiratory depression (RR 8, SpO₂ 88%) is immediately life-threatening — ABC priority. Assess airway and breathing first. May need: stimulation, supplemental O₂, repositioning, reversal agent (naloxone if opioid OD). Others can wait.
Question 114 of 150
A patient is receiving heparin IV. What lab value must the nurse monitor?
Explanation: Heparin is monitored by aPTT. Warfarin is monitored by INR/PT. Therapeutic heparin: aPTT 60-100 seconds. Check aPTT 6 hours after any rate change. Antidote: protamine sulfate. Risk: HIT (heparin-induced thrombocytopenia).
Question 115 of 150
What are signs of digoxin toxicity?
Explanation: Digoxin toxicity: narrow therapeutic index (0.5-2.0 ng/mL). Signs: bradycardia (< 60 bpm hold dose), GI (nausea, vomiting, anorexia), neuro (confusion, visual halos). Risk factors: hypokalaemia. Antidote: Digibind (Digoxin Fab fragments).
Question 116 of 150
A post-operative patient has not voided in 8 hours. What should the nurse do first?
Explanation: Assessment first. Bladder scan: > 300 mL = distension. Interventions: privacy, running water, warm perineal wash. If conservative measures fail: straight catheterisation. Only then consider Foley. Document output. Report if no void in 8 hours post-op.
Question 117 of 150
A patient has just returned from cardiac catheterisation via the right femoral artery. What is the nursing priority?
Explanation: Femoral artery access: risk of bleeding, haematoma, arterial spasm. Assess: groin site (bleeding), distal pulses (circulation), sensation, colour. Keep leg straight for 2-6 hours. Monitor vital signs. Sandbag may be used. Report: absent pulse, expanding haematoma, pallor.
Question 118 of 150
What is the therapeutic lithium level?
Explanation: Therapeutic lithium: 0.5-1.5 mEq/L (acute mania: 1.0-1.5, maintenance: 0.6-1.2). Toxic > 1.5 mEq/L. Signs of toxicity: tremors, GI symptoms, ataxia, confusion. Severe toxicity (> 3.0): seizures, cardiac arrhythmias. Adequate hydration and Na⁺ intake essential.
Question 119 of 150
A patient's potassium level is 2.8 mEq/L. What is the nurse's priority concern?
Explanation: Normal K⁺: 3.5-5.0 mEq/L. Hypokalaemia (< 3.5): priority concern is cardiac arrhythmias (PVCs, V-tach, V-fib). Other signs: muscle weakness, cramps, fatigue, flattened T waves on ECG. IV K⁺ replacement: never IV push, always diluted and slow.
Question 120 of 150
Which finding indicates a complication following a blood transfusion?
Explanation: Haemolytic transfusion reaction (ABO incompatibility): most severe type. Signs: fever, chills, back/flank pain, haematuria (haemoglobin in urine), hypotension, anxiety. Action: STOP transfusion immediately, maintain IV access with saline, notify blood bank and physician.
Question 121 of 150
A patient with COPD has an SpO₂ of 85%. The nurse prepares to administer oxygen. At what flow rate?
Explanation: COPD: hypoxic drive. High O₂ can suppress breathing stimulus → CO₂ retention. Start low: 1-2 L/min NC. Target SpO₂: 88-92%. Monitor for CO₂ retention (drowsiness, confusion, decreased RR). Not withhold O₂ if critically hypoxic — just use lowest effective dose.
Question 122 of 150
What is the most important action before administering any medication?
Explanation: 5 Rights (or 6–8 Rights in some systems): Right Patient (2 identifiers), Right Drug (3 checks), Right Dose (calculate), Right Route, Right Time, Right Documentation. Two identifiers: name + DOB, or name + MRN. Never verify by room number alone.
Question 123 of 150
A patient with a chest tube suddenly reports severe pain and the water seal chamber is bubbling continuously. What should the nurse do?
Explanation: Continuous bubbling in water seal = air leak. Check connections from chest to collection system. If connections tight: leak is from patient (expected with pneumothorax). Clamp tube briefly to locate leak. Tension pneumothorax (absent breath sounds, tracheal deviation, hypotension): emergency — never clamp.
Question 124 of 150
A patient is ordered NPO for surgery. They ask if they can take their morning antihypertensive. What should the nurse do?
Explanation: NPO typically refers to food and non-essential liquids. Essential medications (antihypertensives, cardiac drugs, anticonvulsants) are often given with a small sip of water. Always verify with surgical team. Abrupt withdrawal of antihypertensives can cause rebound hypertension.
Question 125 of 150
Which intervention is most important when a patient is placed in restraints?
Explanation: Restraint care: neurovascular checks every 15-30 minutes, release and reposition every 2 hours, provide ROM exercises, offer toileting, reassess need regularly. Restraints are last resort — require MD order, documentation of rationale and alternatives tried. Never tie to side rails.
Question 126 of 150
A patient with an NG tube has an order for aspirin 325mg. How should the nurse administer it?
Explanation: NG tube medications: crush (if crushable), dissolve in 15-30mL water, give each medication separately, flush 15-30mL water before and after each medication. Check: can the tablet be crushed? (Never crush: extended-release, enteric-coated, sublingual). Aspirin can be crushed.
Question 127 of 150
What laboratory value is most important to check before administering a blood transfusion?
Explanation: Type and crossmatch (T&C) ensures ABO/Rh compatibility. Transfuse ABO-compatible blood only. Before transfusion: check T&C report, verify patient ID (2 identifiers) against blood bag with 2 nurses, check expiry date, inspect bag. Baseline vital signs before starting.
Question 128 of 150
What is the nursing action when a patient experiences a tonic-clonic seizure?
Explanation: Seizure care: safety (do not restrain, remove hazards, pad rails), do not put anything in mouth (no tongue depressors — tour fractures teeth and injures nurse), position on side (recovery position) to prevent aspiration, time seizure, O₂ and suction available, IV access, document.
Question 129 of 150
A patient receiving IV vancomycin develops flushing, erythema, and pruritus on the face and neck. What is this?
Explanation: Red man syndrome: not an allergy (IgE-mediated), an infusion reaction to rapid vancomycin. Management: slow infusion rate (infuse over at least 60 minutes), pre-medicate with diphenhydramine if needed. If true allergy (anaphylaxis): stop drug, epinephrine, different antibiotic.
Question 130 of 150
What are the early signs of increased intracranial pressure (ICP)?
Explanation: Early ICP signs: restlessness, headache, nausea, subtle LOC changes. Late signs (Cushing's triad): bradycardia, hypertension with widening pulse pressure, irregular respirations (Cheyne-Stokes). Interventions: HOB 30°, avoid Valsalva, avoid hip flexion, O₂, quiet environment.
Question 131 of 150
What is the normal serum sodium level?
Explanation: Normal Na⁺: 135-145 mEq/L. Hyponatraemia (< 135): dilution (SIADH, water intoxication) or depletion (diarrhoea, diuretics). Signs: confusion, seizures. Hypernatraemia (> 145): water deficit or excess Na⁺. Signs: thirst, agitation, seizures.
Question 132 of 150
A patient with a newly applied cast reports severe pain unrelieved by analgesics and paresthesia. What does tour indicate?
A patient is ordered NPH insulin 20 units and regular insulin 10 units mixed in the same syringe. What is drawn up first?
Explanation: 'Clear before cloudy': regular (clear) drawn first to prevent contamination of regular insulin vial with NPH (cloudy). If NPH enters regular vial, it changes regular insulin's action. Memory: Regular = clear, R-regular = R comes first.
Question 134 of 150
What is a priority nursing concern for a patient with a new colostomy?
Explanation: Healthy stoma: pink/red, moist. Dark (blue-black): ischaemia. Pale: anaemia or ischaemia. Dusky: venous congestion. Report abnormal colour immediately. Also monitor: output (ileal stoma: liquid, colostomy: more formed), skin integrity around stoma, teaching patient ostomy care.
Question 135 of 150
Which is the priority nursing action for a patient who pulls out their endotracheal tube?
Explanation: Self-extubation: maintain patent airway first. Manual ventilation with bag-valve-mask if needed. Call RRT/code if apnoea. Have suction, O₂, and intubation equipment ready. Assess respiratory status. Prevention: assess need for restraints, sedation titration, frequent assessment for extubation readiness.
Question 136 of 150
What is the priority nursing assessment for a patient receiving total parenteral nutrition (TPN)?
Explanation: TPN complications: hyperglycaemia (most common — monitor glucose every 4-6 hours, give insulin as ordered), infection (central line — strict aseptic technique), rebound hypoglycaemia (if stopped suddenly — taper), fluid overload, electrolyte imbalances. Change tubing every 24 hours.
Question 137 of 150
A patient with a suspected MI is prescribed aspirin 325mg. They say they are allergic to aspirin. What should the nurse do?
Explanation: Clarify allergy type before withholding critical medication. True aspirin allergy (anaphylaxis, urticaria): contraindicated — notify physician for alternative (clopidogrel). GI intolerance is not a true allergy — physician may still order given MI risk. Always document and communicate.
What is the difference between infiltration and extravasation of IV fluids?
Explanation: IV site complications: Infiltration: non-vesicant (saline, D5W) leaks → swelling, coolness, pain, slowed flow. Stop infusion, remove IV, apply warm compress. Extravasation: vesicant (chemo, phenytoin, dopamine) leaks → potential necrosis. Emergency: stop, aspirate, antidote per protocol, plastic surgery consult.
Question 142 of 150
A patient taking warfarin reports eating large amounts of green leafy vegetables daily. What is the concern?
Explanation: Warfarin and Vitamin K: Vitamin K is the antidote to warfarin. Inconsistent intake causes fluctuating INR. Educate: consistent (not zero) vitamin K intake. Monitor INR regularly. Significant interactions: many antibiotics (decrease gut flora that make Vit K), NSAIDs (increase bleeding risk), aspirin.
Question 143 of 150
A patient with heart failure is prescribed furosemide. What electrolyte must be monitored closely?
Explanation: Furosemide (Lasix): loop diuretic — blocks Na/K/Cl transport in loop of Henle. Causes potassium loss → hypokalaemia → cardiac arrhythmia risk. Monitor K⁺ before each dose. Give with food. Potassium supplementation often needed. Check digoxin level if patient is on both (hypokalaemia increases digoxin toxicity risk).
Question 144 of 150
What is the correct position for a patient in hypovolemic shock?
Explanation: Hypovolemic shock: priority = increase perfusion to vital organs. Elevate legs (passive leg raise) → increases venous return. Flat position. High Fowler's used for respiratory distress. Left lateral for: birthing (relieve aortocaval compression), liver biopsy, left-sided cardiac procedures. Prone: ARDS (improves oxygenation).
Question 145 of 150
A patient's NG tube feeding is running. They vomit and appear distressed. What should the nurse do first?
Explanation: Vomiting with NG feeding: aspiration risk is immediate concern. Stop feeding → prevent more from running. Side position → drainage, not aspiration. Suction if needed. Assess: breath sounds (aspiration signs), oxygen saturation. Check residual before next feeding. Report to physician.
Question 146 of 150
A post-operative patient has a urine output of 20 mL over the last hour. What action does the nurse take first?
Explanation: Oliguria (< 30 mL/hr): assess first. Check: catheter patency (kinked, clamped), blood pressure, fluid balance, pain (can cause urinary retention). Pre-renal (dehydration): fluid challenge may be ordered. Intrinsic renal: investigate cause. Post-renal: relieve obstruction. Notify physician after assessment.
Question 147 of 150
A patient is prescribed metformin for type 2 diabetes. What is the most important teaching point?
Explanation: Metformin and contrast: IV iodinated contrast can temporarily impair renal function → metformin accumulates → lactic acidosis (rare but serious). Standard practice: hold metformin at time of procedure, restart 48 hours later if creatinine is normal. Metformin first-line for T2DM. Does not cause hypoglycaemia alone.
Question 148 of 150
A patient newly diagnosed with tuberculosis is placed in a room. What type of precautions are required?
Explanation: TB airborne precautions: N-95 respirator for all who enter room (not just surgical mask). Negative pressure room (air flows in, not out). Door kept closed. Patient: surgical mask when outside room. Treatment: minimum 6 months of RIPE therapy (Rifampin, Isoniazid, Pyrazinamide, Ethambutol). Directly observed therapy (DOT) recommended.
Question 149 of 150
A patient with chronic kidney disease has a potassium level of 5.8 mEq/L. Which food should the nurse advise the patient to avoid?
Explanation: Hyperkalaemia diet in CKD: avoid high-K foods: bananas, oranges, potatoes, tomatoes, legumes, nuts, avocado, dairy. Choose: apples, berries, white rice, pasta, white bread. Cooking method: leaching vegetables (peeling, cutting small, boiling in large water, discarding water) reduces potassium content.
Question 150 of 150
A nurse prepares to administer a blood transfusion. The patient develops fever and chills 20 minutes in. What is the first action?
Explanation: Transfusion reaction protocol: STOP immediately. Maintain IV with NS (don't disconnect). Assess: vital signs, urine colour (haematuria = haemolytic reaction). Notify physician and blood bank. Send: blood bag, tubing, and patient blood/urine samples to lab. Fever alone may be febrile non-haemolytic reaction (most common) but cannot exclude haemolytic reaction.
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In NCLEX, Maslow's Hierarchy guides prioritisation: physiological needs (airway, breathing, circulation) are always the highest priority. Safety is second. Psychosocial needs (love, esteem, self-actualisation) come last. When a question asks what to address first, select the physiological/safety concern over emotional or educational needs.
ABCs stands for Airway, Breathing, Circulation. In any emergency or prioritisation question, assess and address in tour order. An obstructed airway is the most immediately life-threatening — no airway means no breathing means no circulation. NCLEX questions testing prioritisation almost always reward the answer that addresses airway first.
Assignment is directing an RN to perform a task within their normal scope of practice. Delegation is transferring responsibility for a nursing task to a person who would not normally perform it (e.g., an LPN or UAP). The RN retains accountability. Delegate tasks that are stable, routine, and non-complex. Never delegate assessment, teaching, or unstable patients.
Normal blood pressure for an adult is less than 120/80 mmHg. Elevated: 120–129 systolic, <80 diastolic. Stage 1 hypertension: 130–139/80–89. Stage 2 hypertension: ≥140/≥90. Hypertensive crisis: >180/120. Hypotension: <90/60. On NCLEX, values outside normal range require immediate nursing assessment.
When a patient reports chest pain: (1) Assess the pain (PQRST: Provocation, Quality, Radiation, Severity, Time). (2) Position upright/semi-Fowler's to ease breathing. (3) Obtain vital signs. (4) Apply oxygen if saturation is low. (5) Obtain a 12-lead ECG. (6) Notify the physician immediately. (7) Establish IV access if not present.
Therapeutic communication is a purposeful, goal-directed form of communication aimed at promoting client wellbeing. Techniques include: open-ended questions ('Tell me about...'), reflection, clarification, silence, and empathy. Non-therapeutic responses include: giving advice, false reassurance ('Everything will be fine'), using medical jargon, and changing the subject.
The five rights of safe medication administration are: (1) Right Patient — verify two identifiers. (2) Right Drug — check three times. (3) Right Dose — calculate carefully. (4) Right Route — oral, IV, IM, subcutaneous. (5) Right Time — check frequency and last dose. Some institutions add Right Documentation as a sixth right.
Normal serum potassium is 3.5–5.0 mEq/L. Hypokalemia (<3.5): muscle weakness, cramping, cardiac arrhythmias, ECG changes (flattened T waves, U waves). Hyperkalemia (>5.0): muscle weakness, peaked T waves, widened QRS, cardiac arrest. Always check renal function and ECG with potassium abnormalities. Potassium is never given IV push.