NCLEX-RN sample questions, with rationales

B: A client with a femur fracture who is suddenly confused and short of breath, with a SpO2 of 86%. Sudden confusion, dyspnea and hypoxemia after a long-bone fracture suggest fat embolism syndrome, which is life-threatening. The other findings are expected for those conditions.

The trap: Choosing a client whose finding sounds dramatic but is expected. Phantom pain, itching under a cast and aphasia after a stroke fit the condition; new confusion and hypoxemia after a long-bone fracture do not.

C: A client with pneumonia who is newly restless, with a respiratory rate of 30 and SpO2 of 87%. New restlessness with tachypnea and an SpO2 of 87% is acute hypoxemia, a breathing problem that is getting worse. The other three are expected or chronic and stable.

1. Sort each client: acute or chronic, expected or unexpected, stable or unstable.
2. Glucose 182, pain 5 after surgery and morning stiffness are expected for those conditions.
3. Restlessness, RR 30 and SpO2 87% are new, unexpected and about breathing: see that client first.

The trap: Picking the "number" (glucose 182) because it is abnormal. Abnormal is not the same as unstable: the question is who could deteriorate in the next few minutes.

C: Helping a stable client 3 days after knee surgery to the bathroom. Helping a stable client with toileting is a routine task with a predictable outcome. Teaching, assessment and monitoring a transfusion start need the RN's judgment.

1. Ask of each task: does it need assessment, teaching, evaluation or judgment?
2. Teaching, skin assessment and early transfusion monitoring do.
3. Assisting a stable client to the bathroom does not: delegate it, with instructions on what to report.

The trap: Delegating "monitoring" because it sounds like taking vital signs. Watching for a transfusion reaction is assessment, which stays with the RN.

C: Notify the surgeon that the client has questions before the procedure. A question like this shows the consent may not be fully informed. Explaining the procedure is the surgeon's job, so the nurse contacts the surgeon before the procedure goes ahead.

1. Who explains the procedure? The provider performing it.
2. A signed form does not mean the client understands.
3. So the nurse notifies the surgeon and the procedure waits until the question is answered.

The trap: Answering the question yourself because you know the answer. The nurse witnesses and advocates; the surgeon explains.

B: An airborne infection isolation room and an N95 respirator. Measles is airborne: a negative-pressure airborne infection isolation room with the door closed, and a fit-tested N95 or higher respirator for staff.

1. Name the route: measles spreads through the air.
2. Airborne precautions mean negative pressure and an N95.
3. Droplet (surgical mask) and contact (gloves) precautions are not enough.

The trap: Choosing droplet precautions because measles is "a respiratory virus". The airborne three to learn are measles, varicella and tuberculosis.

C: Comparing the client's name and date of birth on the wristband with the medication record. Two identifiers, compared against the record, is The Joint Commission standard. Room numbers change and yes-or-no questions invite a confused client to agree.

1. The rule is two identifiers, such as name and date of birth.
2. A room number is never an identifier.
3. Compare against the record, not against memory.

The trap: Asking a yes-or-no question. A client who is confused, hard of hearing or sedated may say yes to any name.

B: Stop the transfusion. A suspected transfusion reaction means stop the transfusion first, keep the IV open with normal saline through new tubing, notify the provider and blood bank, and send the bag and tubing back.

The trap: Slowing the transfusion. A suspected reaction always means stop it first, then keep the vein open with normal saline through new tubing.

C: 2 tablets. Desired over have: 50 mg ÷ 25 mg per tablet = 2 tablets.

D: 12 hours 30 minutes. 1,000 mL ÷ 80 mL/h = 12.5 hours, which is 12 hours 30 minutes.

C: 0.5 mL. 15 mg ÷ 30 mg/mL = 0.5 mL.

D: 7.5 mL. 150 mg ÷ 100 mg × 5 mL = 7.5 mL.

A: 28 mL/h. 25,000 units ÷ 500 mL = 50 units/mL; 1,400 units/h ÷ 50 units/mL = 28 mL/h.

D: 28.1 mL/h. 10 mcg/kg/min × 75 kg = 750 mcg/min; × 60 = 45,000 mcg/h; ÷ 1,600 mcg/mL = 28.1 mL/h.

B: 31.9 mL/h. 10 mcg/kg/min × 85 kg = 850 mcg/min; × 60 = 51,000 mcg/h; ÷ 1,600 mcg/mL = 31.9 mL/h.

C: 125 mL/h. 1,000 mL ÷ 8 h = 125 mL/h, which rounds to 125 mL/h.

B: 31 gtt/min. 1,000 mL × 15 gtt/mL ÷ 480 minutes = 31.25, which rounds to 31 gtt/min.

1. Change hours to minutes: 8 × 60 = 480 min.
2. Multiply volume by drop factor: 1,000 × 15 = 15,000 gtt.
3. Divide: 15,000 ÷ 480 = 31.25, so 31 gtt/min.

The trap: 125 is the pump rate in mL/h. On a gravity set you need drops per minute, so the drop factor and the 60 both come in.

B: 187.5 mg. 33 lb ÷ 2.2 = 15 kg; 15 × 25 = 375 mg a day; divided into two doses, 187.5 mg each.

1. Convert: 33 ÷ 2.2 = 15 kg.
2. Daily dose: 15 kg × 25 mg/kg/day = 375 mg/day.
3. Per dose: 375 ÷ 2 = 187.5 mg.

The trap: 375 mg is the whole day's amount. "mg/kg/day in divided doses" always means one more division.

B: Vitamin K (phytonadione). Vitamin K reverses warfarin; with serious bleeding, prothrombin complex concentrate may be given too. Protamine reverses heparin.

1. Which drug? Warfarin.
2. Its reversal agent: vitamin K.
3. Protamine is for heparin, naloxone for opioids, acetylcysteine for acetaminophen.

The trap: Mixing up the two anticoagulant antidotes. Pair them once and keep them: heparin-protamine, warfarin-vitamin K.

B: Tall, peaked T waves. ACE inhibitors retain potassium, and with a supplement the level can climb. Hyperkalemia peaks the T waves first; U waves and flat T waves belong to hypokalemia.

1. ACE inhibitor plus potassium supplement: risk of hyperkalemia.
2. 6.2 mEq/L is above the typical 3.5 to 5.0 range.
3. High potassium: tall, peaked T waves, then a widening QRS.

The trap: Learning ECG signs as a list. Learn them as opposites: low potassium flattens and adds U waves, high potassium peaks.

C: Sit the client upright. This is autonomic dysreflexia. Sitting upright lowers blood pressure; the nurse then looks for the trigger, most often a full bladder or bowel, and loosens tight clothing.

The trap: Laying the client flat, the reflex for low blood pressure. In autonomic dysreflexia the pressure is dangerously high, so sit the client up, then find the trigger.

A: Suction the tracheostomy. Noisy breathing with falling saturation in a client with a tracheostomy is most often secretions blocking the tube. Suctioning clears the airway at once; calling for help follows if it does not.

1. What is the threat? Airway obstruction.
2. Most likely cause with a trach: secretions.
3. The fix within the nurse's scope that opens the airway now: suction.

The trap: "Notify the provider" is never first when the nurse can fix the airway in seconds. Act, then report.

B: Add dextrose to the IV fluids and continue the insulin. Insulin is continued until the ketoacidosis closes. Adding dextrose once glucose falls to about 200 to 250 mg/dL prevents hypoglycemia while insulin clears the ketones.

1. Insulin treats the acidosis, not only the glucose.
2. Glucose falls faster than ketones clear.
3. So add dextrose and keep the insulin running.

The trap: Stopping insulin because the glucose looks better. The anion gap, not the glucose, decides when the insulin can stop.

B: A sudden severe headache with vomiting. A sudden severe headache with vomiting during thrombolysis suggests intracranial bleeding. The infusion is stopped at once and an emergency CT is expected. A swallow screen comes before any drink.

1. The main risk of alteplase is bleeding, most dangerously in the brain.
2. Headache, vomiting and a neuro change are signs of it.
3. Stop the infusion and call the provider.

The trap: Reacting to the blood pressure. 150/88 is within the usual limit for the first 24 hours after alteplase (under 180/105).

A: Platelets fell from 250,000 to 95,000/mm³ over 6 days. A fall in platelets of more than 50% about 5 to 10 days into heparin suggests heparin-induced thrombocytopenia, which raises the risk of clots. Heparin is stopped and the provider notified.

1. What does heparin cause that labs show? HIT.
2. Platelets from 250,000 to 95,000 is a fall of more than half.
3. Timing (day 6) fits HIT: report it.

The trap: Looking only for the "out of range" number. A therapeutic aPTT is the goal, while the platelet trend is the danger.

A: The client had hives after IV contrast dye in the past. A previous reaction to iodinated contrast is the strongest risk factor for another one; the provider may premedicate or change the study. A shellfish allergy alone is no longer thought to predict contrast reactions.

1. IV contrast risks: allergic-type reaction and kidney injury.
2. A past contrast reaction is the key history.
3. Report it before the scan.

The trap: Asking only about shellfish. The question that matters is a past reaction to contrast itself, plus kidney function and metformin.

B: Move the crutches and the right (weak) leg down first, then the left leg. "Up with the good, down with the bad": going down, the crutches and the weak leg move first so the strong leg lowers the body.

1. Going down stairs?
2. "Down with the bad": crutches and weak leg first.
3. Then the strong leg follows.

The trap: Using the going-up rule. Up, the strong leg leads; down, the crutches and weak leg lead.

A: Stop the feeding. Sudden coughing and desaturation during a feeding suggest aspiration. Stopping the feeding prevents more formula entering the lungs; then suction, assess and notify.

1. What is happening? Likely aspiration.
2. What stops it getting worse? Stop the feeding.
3. Then keep the head raised, suction and notify the provider.

The trap: Flushing or checking residuals. Both put the airway second; anything that adds fluid can make aspiration worse.

B: Ask the client directly whether they are thinking of killing themselves. A veiled statement may be a sign of suicidal thinking. Asking directly does not plant the idea; it tells the nurse how urgent the risk is and what safety measures are needed.

The trap: Offering reassurance or changing the subject. A veiled statement about not mattering needs a direct question about suicide.

B: Stop the oxytocin infusion. Contractions this frequent and long are tachysystole, and late decelerations show the fetus is not getting enough oxygen. Stopping the oxytocin is the first step; side-lying, IV fluid and notifying the provider follow.

1. Spot the cause: oxytocin is overstimulating the uterus.
2. Remove the cause first: stop the infusion.
3. Then reposition to the side, give an IV fluid bolus and notify the provider.

The trap: Choosing oxygen or repositioning first. They help, but while the oxytocin runs the cause of the problem is still being infused.

B: Large, soft stacking blocks. At 10 months infants sit well, bang and stack objects and put things in their mouths. Large soft blocks fit the skill and are not a choking risk.

1. What can a 10-month-old do? Sit, grasp, bang, stack.
2. What is dangerous? Small parts (choking).
3. So large, soft blocks.

The trap: Ignoring safety. Even if a toy fits the skill, anything small enough to swallow is wrong for an infant.

B: "This must be very hard for you. Tell me what you are feeling.". Acknowledging the feeling and inviting the client to talk is therapeutic. Clichés, advice and false reassurance block the conversation.

1. The client is expressing a feeling, not asking for facts.
2. Look for the option that names the feeling and opens the door.
3. Rule out advice, reassurance and platitudes.

The trap: Choosing reassurance because it sounds kind. On the NCLEX, "don't worry" is almost always the wrong answer.

B: Assess the client directly for suicidal thoughts and a plan. Sudden calm and giving away possessions can mean the client has made a decision to die. The nurse asks directly about thoughts, a plan and means, and puts safety measures in place.

1. A sudden change in mood after depression is a warning sign.
2. Giving away possessions is another.
3. Ask directly about suicide and act on the answer.

The trap: Reading calm as recovery. In depression, a sudden lift with these signs needs assessment, not praise.