NCLEX-Style Practice Questions: Nursing Exam 4 Review
(2026/2027)
Comprehensive Nursing Knowledge Synthesis | Key Domains: Advanced Medical-Surgical Nursing,
Complex Maternal-Newborn Care, Pediatric & Adolescent Health, Mental Health Crisis Management,
Leadership & Delegation in Acute Care, and Pharmacology for Complex Conditions | Expert-Aligned
Structure | NCLEX-Style Review Format
Introduction
This structured NCLEX-Style Nursing Exam 4 Review for 2026/2027 provides a comprehensive set
of practice questions designed to simulate the breadth and depth of the NCLEX-RN. It emphasizes
the synthesis of knowledge across multiple content areas, prioritization of care in complex
scenarios, and the application of clinical judgment necessary for safe and effective entry-level
nursing practice.
Review Structure:
• Comprehensive NCLEX-Style Review: (100 INTEGRATED QUESTIONS)
Answer Format
All correct answers must appear in bold and cyan blue, accompanied by concise rationales
explaining the priority nursing action based on a multi-system presentation (e.g., a pregnant
diabetic patient in shock), the pathophysiological link between a disorder and its complication, the
safe delegation of tasks in a busy unit, and why alternative options demonstrate incorrect
prioritization, unsafe practice, or a lack of clinical synthesis.
1. A client with heart failure and type 2 diabetes is prescribed metformin and furosemide.
The nurse notes a serum creatinine of 2.1 mg/dL (baseline 1.0). What is the priority action?
A. Administer both medications as scheduled
B. Hold metformin and notify the provider
C. Increase IV fluids to flush the kidneys
D. Discontinue furosemide immediately
,B. Hold metformin and notify the provider
Metformin is contraindicated in acute or chronic kidney disease (eGFR <30 or acute rise in creatinine)
due to risk of lactic acidosis. Furosemide may contribute to renal impairment but is often continued
with monitoring. Holding metformin and alerting the provider integrates pharmacology and med-surg
knowledge to prevent life-threatening complications.
2. A 16-year-old pregnant client refuses a recommended cesarean section for fetal distress.
Her parents consent, but she states, “I don’t want surgery.” What should the nurse do?
A. Proceed with surgery based on parental consent
B. Respect the minor’s refusal and notify the ethics committee
C. Administer sedation to facilitate surgery
D. Delay surgery until court order is obtained
B. Respect the minor’s refusal and notify the ethics committee
In many jurisdictions, a mature minor can consent to or refuse treatment if deemed competent. For
non-emergent but serious decisions like C-section, her refusal must be respected while seeking
ethics/legal consultation. Proceeding without consent (A, C) violates autonomy. Delay (D) may risk the
fetus, but immediate action requires due process.
3. A 2-year-old presents with acute stridor, drooling, and sitting upright in distress.
Temperature is 103°F. What is the priority action?
A. Administer nebulized albuterol
B. Prepare for intubation in a controlled setting
C. Obtain a throat culture
D. Give acetaminophen for fever
B. Prepare for intubation in a controlled setting
,This is classic epiglottitis—a medical emergency. Do not examine the throat or cause distress. Secure
the airway in a controlled environment (e.g., OR with anesthesia). Albuterol (A) is for asthma. Throat
culture (C) and antipyretics (D) are contraindicated until airway is secure.
4. A client with schizophrenia off antipsychotics says, “The neighbors are poisoning my
water.” What is the priority action?
A. Contact the landlord to test the water
B. Assess for risk of harm to self or others
C. Educate on importance of medication adherence
D. Arrange outpatient psychiatric follow-up
B. Assess for risk of harm to self or others
Safety is paramount in mental health crises. Paranoia may escalate to violence or self-harm.
Assessment of immediate risk guides next steps (e.g., hospitalization). Education (C) and follow-up (D)
are important but secondary. Testing water (A) validates delusion and is inappropriate.
5. A charge nurse is assigning clients for the shift. Which client is most appropriate to assign
to a licensed practical nurse (LPN)?
A. Client with heart failure receiving a new IV dobutamine infusion
B. Client 12 hours post-op from hip arthroplasty with stable vital signs
C. Client admitted with diabetic ketoacidosis requiring hourly glucose checks
D. Client with a new pulmonary embolism on heparin infusion
B. Client 12 hours post-op from hip arthroplasty with stable vital signs
This client is stable with predictable outcomes—within LPN scope. Clients on IV vasoactive drips (A),
anticoagulants (D), or with unstable metabolic conditions (C) require RN-level assessment and
intervention per the NCSBN Five Rights of Delegation.
, 6. An 80-year-old client taking sertraline, metoprolol, and acetaminophen reports fatigue
and dizziness. Which medication is most likely contributing?
A. Sertraline
B. Metoprolol
C. Acetaminophen
D. All equally
B. Metoprolol
Beta-blockers like metoprolol commonly cause bradycardia, fatigue, and orthostatic hypotension in
older adults due to reduced drug metabolism and heightened sensitivity. Sertraline may cause fatigue
but less dizziness. Acetaminophen is unlikely to cause these symptoms at therapeutic doses.
7. A client with end-stage cancer and DNR status has severe pain. The family says, “Don’t give
opioids—he might stop breathing.” What is the nurse’s best response?
A. “I’ll withhold opioids to respect your wishes.”
B. “Opioids are essential for comfort and won’t hasten death when used appropriately.”
C. “Let’s use only non-drug methods like massage.”
D. “The DNR means we can’t give any strong medications.”
B. “Opioids are essential for comfort and won’t hasten death when used appropriately.”
In palliative care, opioids relieve suffering and do not shorten life when titrated to effect. Withholding
pain relief (A, C) causes unnecessary suffering. DNR (D) refers only to resuscitation, not comfort
measures. The nurse must advocate for ethical, evidence-based symptom management.
8. A 10 kg child with asthma is prescribed albuterol 0.15 mg/kg/dose nebulizer. Available:
0.5% solution (5 mg/mL). How many mL should the nurse administer?
A. 0.3 mL
(2026/2027)
Comprehensive Nursing Knowledge Synthesis | Key Domains: Advanced Medical-Surgical Nursing,
Complex Maternal-Newborn Care, Pediatric & Adolescent Health, Mental Health Crisis Management,
Leadership & Delegation in Acute Care, and Pharmacology for Complex Conditions | Expert-Aligned
Structure | NCLEX-Style Review Format
Introduction
This structured NCLEX-Style Nursing Exam 4 Review for 2026/2027 provides a comprehensive set
of practice questions designed to simulate the breadth and depth of the NCLEX-RN. It emphasizes
the synthesis of knowledge across multiple content areas, prioritization of care in complex
scenarios, and the application of clinical judgment necessary for safe and effective entry-level
nursing practice.
Review Structure:
• Comprehensive NCLEX-Style Review: (100 INTEGRATED QUESTIONS)
Answer Format
All correct answers must appear in bold and cyan blue, accompanied by concise rationales
explaining the priority nursing action based on a multi-system presentation (e.g., a pregnant
diabetic patient in shock), the pathophysiological link between a disorder and its complication, the
safe delegation of tasks in a busy unit, and why alternative options demonstrate incorrect
prioritization, unsafe practice, or a lack of clinical synthesis.
1. A client with heart failure and type 2 diabetes is prescribed metformin and furosemide.
The nurse notes a serum creatinine of 2.1 mg/dL (baseline 1.0). What is the priority action?
A. Administer both medications as scheduled
B. Hold metformin and notify the provider
C. Increase IV fluids to flush the kidneys
D. Discontinue furosemide immediately
,B. Hold metformin and notify the provider
Metformin is contraindicated in acute or chronic kidney disease (eGFR <30 or acute rise in creatinine)
due to risk of lactic acidosis. Furosemide may contribute to renal impairment but is often continued
with monitoring. Holding metformin and alerting the provider integrates pharmacology and med-surg
knowledge to prevent life-threatening complications.
2. A 16-year-old pregnant client refuses a recommended cesarean section for fetal distress.
Her parents consent, but she states, “I don’t want surgery.” What should the nurse do?
A. Proceed with surgery based on parental consent
B. Respect the minor’s refusal and notify the ethics committee
C. Administer sedation to facilitate surgery
D. Delay surgery until court order is obtained
B. Respect the minor’s refusal and notify the ethics committee
In many jurisdictions, a mature minor can consent to or refuse treatment if deemed competent. For
non-emergent but serious decisions like C-section, her refusal must be respected while seeking
ethics/legal consultation. Proceeding without consent (A, C) violates autonomy. Delay (D) may risk the
fetus, but immediate action requires due process.
3. A 2-year-old presents with acute stridor, drooling, and sitting upright in distress.
Temperature is 103°F. What is the priority action?
A. Administer nebulized albuterol
B. Prepare for intubation in a controlled setting
C. Obtain a throat culture
D. Give acetaminophen for fever
B. Prepare for intubation in a controlled setting
,This is classic epiglottitis—a medical emergency. Do not examine the throat or cause distress. Secure
the airway in a controlled environment (e.g., OR with anesthesia). Albuterol (A) is for asthma. Throat
culture (C) and antipyretics (D) are contraindicated until airway is secure.
4. A client with schizophrenia off antipsychotics says, “The neighbors are poisoning my
water.” What is the priority action?
A. Contact the landlord to test the water
B. Assess for risk of harm to self or others
C. Educate on importance of medication adherence
D. Arrange outpatient psychiatric follow-up
B. Assess for risk of harm to self or others
Safety is paramount in mental health crises. Paranoia may escalate to violence or self-harm.
Assessment of immediate risk guides next steps (e.g., hospitalization). Education (C) and follow-up (D)
are important but secondary. Testing water (A) validates delusion and is inappropriate.
5. A charge nurse is assigning clients for the shift. Which client is most appropriate to assign
to a licensed practical nurse (LPN)?
A. Client with heart failure receiving a new IV dobutamine infusion
B. Client 12 hours post-op from hip arthroplasty with stable vital signs
C. Client admitted with diabetic ketoacidosis requiring hourly glucose checks
D. Client with a new pulmonary embolism on heparin infusion
B. Client 12 hours post-op from hip arthroplasty with stable vital signs
This client is stable with predictable outcomes—within LPN scope. Clients on IV vasoactive drips (A),
anticoagulants (D), or with unstable metabolic conditions (C) require RN-level assessment and
intervention per the NCSBN Five Rights of Delegation.
, 6. An 80-year-old client taking sertraline, metoprolol, and acetaminophen reports fatigue
and dizziness. Which medication is most likely contributing?
A. Sertraline
B. Metoprolol
C. Acetaminophen
D. All equally
B. Metoprolol
Beta-blockers like metoprolol commonly cause bradycardia, fatigue, and orthostatic hypotension in
older adults due to reduced drug metabolism and heightened sensitivity. Sertraline may cause fatigue
but less dizziness. Acetaminophen is unlikely to cause these symptoms at therapeutic doses.
7. A client with end-stage cancer and DNR status has severe pain. The family says, “Don’t give
opioids—he might stop breathing.” What is the nurse’s best response?
A. “I’ll withhold opioids to respect your wishes.”
B. “Opioids are essential for comfort and won’t hasten death when used appropriately.”
C. “Let’s use only non-drug methods like massage.”
D. “The DNR means we can’t give any strong medications.”
B. “Opioids are essential for comfort and won’t hasten death when used appropriately.”
In palliative care, opioids relieve suffering and do not shorten life when titrated to effect. Withholding
pain relief (A, C) causes unnecessary suffering. DNR (D) refers only to resuscitation, not comfort
measures. The nurse must advocate for ethical, evidence-based symptom management.
8. A 10 kg child with asthma is prescribed albuterol 0.15 mg/kg/dose nebulizer. Available:
0.5% solution (5 mg/mL). How many mL should the nurse administer?
A. 0.3 mL
