Hardest NCLEX Questions for College Nursing Students

1. A nurse administers vancomycin IV over 30 minutes instead of the recommended 60 minutes. The patient develops flushing and hypotension. What is this reaction called?

Anaphylaxis

Red man syndrome

Serum sickness

Stevens-Johnson syndrome

2. A client with liver cirrhosis and portal hypertension develops ascites and hepatic encephalopathy. Which medication addresses both conditions?

Spironolactone alone

Lactulose and rifaxomicin

Propranolol for varices only

Albumin infusion for ascites only

3. A patient with severe hypomagnesemia (0.9 mg/dL) develops cardiac dysrhythmias. Why is magnesium repletion urgent?

Magnesium stabilizes cell membranes and cardiac conduction

Low magnesium directly damages the myocardium

Magnesium is required for ATP synthesis only

Hypomagnesemia causes immediate cardiac arrest

4. A nurse suspects a patient is experiencing compartment syndrome after a crush injury. Which assessment finding is most reliable?

Swelling and warmth of the limb

Pain out of proportion to the injury, unrelieved by opioids

Absence of pedal pulses

Pallor and coolness of the extremity

5. A client with severe pancreatitis develops hypocalcemia. What is the primary cause?

Increased renal excretion of calcium

Saponification of fat and calcium sequestration

Vitamin D deficiency

Hypoparathyroidism

6. A patient with atrial fibrillation on warfarin has an INR of 8.5. What is the most appropriate intervention?

Administer vitamin K 10 mg IV immediately

Give fresh frozen plasma and low-dose vitamin K

Continue warfarin; recheck INR in 24 hours

Hold warfarin only; monitor for bleeding

7. A client in hypovolemic shock receives aggressive IV fluid resuscitation. Which finding suggests inadequate perfusion persists?

Urine output 40 mL/hour

Mean arterial pressure 65 mmHg

Urine output 15 mL/hour with high urine osmolality

Heart rate decreasing to 85 bpm

8. A patient with chronic kidney disease stage 4 has a GFR of 20 mL/min. Which drug requires significant dose adjustment?

Acetaminophen

Gentamicin

Aspirin

Metformin

9. A postoperative patient develops sudden onset dyspnea, chest pain, and hypoxia 2 hours after surgery. What is the priority assessment?

Assess for anxiety-related hyperventilation

Evaluate for pulmonary embolism or pneumothorax

Check pain medication effectiveness

Monitor blood pressure for hypertension

10. A client with pulmonary hypertension and right heart failure develops syncope with exertion. Which medication is contraindicated?

Diuretics for fluid management

Vasodilators for pulmonary vessels

Positive inotropes like dobutamine

Nitrates and phosphodiesterase-5 inhibitors together

11. A client with sepsis develops acute respiratory distress syndrome (ARDS). Which arterial blood gas (ABG) finding is most consistent with early ARDS?

Low PaCO2, low PaO2, high pH

High PaCO2, high PaO2, low pH

Low PaCO2, high PaO2, normal pH

High PaCO2, low PaO2, low pH

12. A patient with sepsis has a lactate level of 4 mmol/L. What does this finding indicate?

Adequate tissue perfusion and oxygenation

Tissue hypoxia and anaerobic metabolism

Liver failure only

Normal metabolic state in infection

13. A client receiving cisplatin chemotherapy develops ototoxicity. Which nursing action is most appropriate?

Continue cisplatin; ototoxicity is reversible

Notify provider; dose reduction or drug discontinuation may be needed

Administer aminoglycosides to enhance drug effect

Increase hydration to minimize drug accumulation

14. A patient with diabetic ketoacidosis has a pH of 7.15, HCO3 of 12, and glucose of 450 mg/dL. What is the primary nursing priority?

Administer rapid-acting insulin to lower glucose

Initiate IV fluids and monitor electrolytes closely

Provide oral carbohydrates to prevent hypoglycemia

Administer sodium bicarbonate to raise pH immediately

15. A client with heart failure is prescribed ACE inhibitor and loop diuretic. Which electrolyte imbalance is most concerning?

Hyperkalemia

Hypokalemia

Hypercalcemia

Hypernatremia

16. A patient with acute myocardial infarction receives fibrinolytic therapy. Which complication requires immediate intervention?

Mild chest discomfort relief

Sudden onset severe headache and altered consciousness

Transient ST-segment elevation normalization

Mild allergic reaction to the thrombolytic agent

17. A postoperative patient has a hemoglobin of 7.2 g/dL, is hemodynamically stable, and asymptomatic. What is the best nursing action?

Transfuse immediately to maintain Hgb above 8 g/dL

Assess symptoms and vital signs; transfuse if symptomatic

Administer iron supplements and recheck in 24 hours

Notify provider; transfuse only if Hgb drops below 7 g/dL

18. A client with end-stage renal disease and a potassium level of 6.8 mEq/L is asymptomatic. Which intervention is most appropriate initially?

Administer sodium polystyrene sulfonate (Kayexalate) only

Perform emergent dialysis immediately

Give calcium gluconate IV, then insulin with glucose

Restrict dietary potassium and reassess in 4 hours

19. A patient receiving heparin infusion develops thrombocytopenia and new thrombotic events. What is the priority nursing action?

Increase heparin dose to achieve therapeutic effect

Discontinue heparin and notify provider immediately

Continue heparin but monitor platelet count daily

Switch to warfarin without stopping heparin

Hardest NCLEX Quiz: Can You Survive the Toughest Qs?