Mastering Pharmacology & Parenteral
Therapy: 150 Challenging NCLEX-Style Multiple-
Choice Questions Covering Drug Mechanisms, IV
Therapy, Calculations, Transfusions, TPN,
Adverse Effects, Interactions, Safety,
Pharmacokinetics, Antidotes, and High-Risk
Medications with Clinical Scenarios and In-Depth
Rationales for Nursing & Healthcare Exam
Preparation Advanced Practice Question Bank
graded A+ 2025/2026
1. A nurse is to administer vancomycin 1 g IVPB. The pharmacy supplies a 500 mL premixed bag
labeled “Vancomycin 1 g in 500 mL” to be infused over 90 minutes. At what rate (mL/hr) should
the infusion pump be set?
A) 167 mL/hr
B) 250 mL/hr
C) 333 mL/hr
D) 500 mL/hr
Correct Answer: C
Rationale: 500 mL ÷ 1.5 hours = 333.3 mL/hr, rounded to 333 mL/hr. Infusing faster risks red
man syndrome (histamine release) with hypotension and flushing; slower rates are safe but
would unnecessarily prolong therapy.
2. A patient receiving total parenteral nutrition (TPN) via a central venous catheter suddenly
develops a temperature of 102°F (38.9°C), chills, and malaise. The nurse suspects a catheter-
related bloodstream infection. Which action should the nurse perform first?
A) Administer the prescribed antipyretic
B) Stop the TPN and infuse dextrose 10% in water at the same rate
C) Change the central line dressing and clean the hub
D) Draw blood cultures from the catheter and a peripheral vein
,Correct Answer: B
Rationale: Stopping the TPN removes the possible infectious source, and switching to dextrose
10% prevents rebound hypoglycemia from the high-dextrose TPN. Cultures and antipyretics
follow, but maintaining glucose is the immediate priority.
3. A patient with atrial fibrillation is receiving a continuous heparin infusion and is started on
amiodarone IV. The nurse should monitor for which expected laboratory change?
A) Decreased activated partial thromboplastin time (aPTT)
B) Increased international normalized ratio (INR)
C) Increased aPTT
D) Decreased platelet count
Correct Answer: C
Rationale: Amiodarone inhibits warfarin metabolism, but this patient is on heparin.
Amiodarone does not directly interact with heparin to affect aPTT. However, amiodarone can
cause hypothyroidism or hyperthyroidism, and it may prolong the QT interval. There is no
predictable increase in aPTT from the combination.
Note: A better pairing would be warfarin + amiodarone causing increased INR. The scenario as
written has a flawed interaction; please substitute with the following corrected question:
3 (Corrected). A patient on stable warfarin therapy is newly prescribed amiodarone. Which
laboratory value should the nurse monitor most closely?
A) aPTT
B) INR
C) Platelet count
D) Serum potassium
Correct Answer: B
Rationale: Amiodarone is a potent inhibitor of CYP2C9, the enzyme that metabolizes warfarin,
leading to increased warfarin effect and elevated INR. Frequent INR monitoring and warfarin
dose adjustment are needed.
4. An older adult with heart failure takes digoxin 0.125 mg daily. Lab results: potassium 3.1
mEq/L, digoxin level 2.2 ng/mL (therapeutic 0.5–2 ng/mL). The patient reports nausea,
anorexia, and seeing “yellow halos.” After checking the apical pulse and finding it 58 bpm and
irregular, what should the nurse do first?
A) Administer the scheduled digoxin and recheck the pulse in 1 hour
B) Hold digoxin, give potassium supplement, and notify the provider
,C) Prepare to administer digoxin immune Fab immediately
D) Give atropine and monitor for bradycardia
Correct Answer: B
Rationale: The patient shows signs of digoxin toxicity (GI, visual, bradycardia) with hypokalemia,
which potentiates toxicity. The nurse should hold the dose, address the low potassium (as
ordered), and notify the provider. Digoxin immune Fab is used for severe toxicity and is not the
first independent nursing action.
5. A patient with a creatinine clearance of 22 mL/min is prescribed enoxaparin 1 mg/kg
subcutaneously every 12 hours for acute DVT treatment. Which laboratory test is most
important to monitor to ensure safety?
A) aPTT
B) Anti–factor Xa activity
C) PT/INR
D) Serum sodium
Correct Answer: B
Rationale: Enoxaparin, a low-molecular-weight heparin, is renally eliminated and accumulates
in severe renal impairment. Routine monitoring is not required, but in reduced renal function,
anti–factor Xa levels should be measured to guide dosing and prevent bleeding. aPTT is not
reliably affected.
6. During a packed RBC transfusion, the patient develops urticaria, pruritus, and mild wheezing.
Vitals: BP 120/78 mm Hg, HR 92 bpm, RR 22. The nurse identifies which type of transfusion
reaction?
A) Febrile nonhemolytic
B) Allergic
C) Acute hemolytic
D) Transfusion-related acute lung injury (TRALI)
Correct Answer: B
Rationale: Urticaria and wheezing without fever or hypotension indicate an allergic reaction,
usually to plasma proteins in the component. Febrile nonhemolytic causes fever, chills;
hemolytic presents with flank pain, fever, hypotension, dark urine; TRALI causes acute
respiratory distress.
, 7. A postoperative patient rates pain as 7/10. The prescription reads: hydromorphone 0.6 mg IV
push every 3 hours PRN. The pharmacy supplies hydromorphone 2 mg/mL. How many mL
should the nurse administer? (Round to the nearest tenth.)
A) 0.2 mL
B) 0.3 mL
C) 0.5 mL
D) 0.6 mL
Correct Answer: B
Rationale: Desired dose (0.6 mg) divided by concentration (2 mg/mL) = 0.3 mL. Use a 1 mL
syringe for accuracy.
8. A patient with type 1 diabetes uses an insulin pump delivering insulin lispro. She is scheduled
for a 2-hour MRI under sedation and will be NPO. The nurse anticipates which plan?
A) Continue the insulin pump at basal rate with hourly glucose checks
B) Discontinue the pump and administer subcutaneous insulin glargine before the procedure
C) Suspend the pump and start an IV regular insulin infusion
D) Remove the pump and give no insulin until the procedure is over
Correct Answer: A
Rationale: Current guidelines allow insulin pump continuation at basal rate during short NPO
periods with frequent blood glucose monitoring to prevent ketoacidosis. An IV insulin infusion is
indicated for major surgery or prolonged fasting. Suspending without basal coverage risks
ketosis.
9. An order reads: infuse 1 unit of apheresed platelets (250 mL) over 30 minutes. The blood
administration set delivers 10 gtt/mL. Calculate the drip rate in gtt/min. (Round to the nearest
whole number.)
A) 42 gtt/min
B) 63 gtt/min
C) 83 gtt/min
D) 125 gtt/min
Correct Answer: C
Rationale: Volume (250 mL) ÷ time (30 min) = 8.33 mL/min × 10 gtt/mL = 83.3 ≈ 83 gtt/min.
10. A patient on phenytoin reports diplopia and unsteady gait. The serum phenytoin level is 28
mcg/mL (therapeutic 10–20). Which nursing action is priority?
Therapy: 150 Challenging NCLEX-Style Multiple-
Choice Questions Covering Drug Mechanisms, IV
Therapy, Calculations, Transfusions, TPN,
Adverse Effects, Interactions, Safety,
Pharmacokinetics, Antidotes, and High-Risk
Medications with Clinical Scenarios and In-Depth
Rationales for Nursing & Healthcare Exam
Preparation Advanced Practice Question Bank
graded A+ 2025/2026
1. A nurse is to administer vancomycin 1 g IVPB. The pharmacy supplies a 500 mL premixed bag
labeled “Vancomycin 1 g in 500 mL” to be infused over 90 minutes. At what rate (mL/hr) should
the infusion pump be set?
A) 167 mL/hr
B) 250 mL/hr
C) 333 mL/hr
D) 500 mL/hr
Correct Answer: C
Rationale: 500 mL ÷ 1.5 hours = 333.3 mL/hr, rounded to 333 mL/hr. Infusing faster risks red
man syndrome (histamine release) with hypotension and flushing; slower rates are safe but
would unnecessarily prolong therapy.
2. A patient receiving total parenteral nutrition (TPN) via a central venous catheter suddenly
develops a temperature of 102°F (38.9°C), chills, and malaise. The nurse suspects a catheter-
related bloodstream infection. Which action should the nurse perform first?
A) Administer the prescribed antipyretic
B) Stop the TPN and infuse dextrose 10% in water at the same rate
C) Change the central line dressing and clean the hub
D) Draw blood cultures from the catheter and a peripheral vein
,Correct Answer: B
Rationale: Stopping the TPN removes the possible infectious source, and switching to dextrose
10% prevents rebound hypoglycemia from the high-dextrose TPN. Cultures and antipyretics
follow, but maintaining glucose is the immediate priority.
3. A patient with atrial fibrillation is receiving a continuous heparin infusion and is started on
amiodarone IV. The nurse should monitor for which expected laboratory change?
A) Decreased activated partial thromboplastin time (aPTT)
B) Increased international normalized ratio (INR)
C) Increased aPTT
D) Decreased platelet count
Correct Answer: C
Rationale: Amiodarone inhibits warfarin metabolism, but this patient is on heparin.
Amiodarone does not directly interact with heparin to affect aPTT. However, amiodarone can
cause hypothyroidism or hyperthyroidism, and it may prolong the QT interval. There is no
predictable increase in aPTT from the combination.
Note: A better pairing would be warfarin + amiodarone causing increased INR. The scenario as
written has a flawed interaction; please substitute with the following corrected question:
3 (Corrected). A patient on stable warfarin therapy is newly prescribed amiodarone. Which
laboratory value should the nurse monitor most closely?
A) aPTT
B) INR
C) Platelet count
D) Serum potassium
Correct Answer: B
Rationale: Amiodarone is a potent inhibitor of CYP2C9, the enzyme that metabolizes warfarin,
leading to increased warfarin effect and elevated INR. Frequent INR monitoring and warfarin
dose adjustment are needed.
4. An older adult with heart failure takes digoxin 0.125 mg daily. Lab results: potassium 3.1
mEq/L, digoxin level 2.2 ng/mL (therapeutic 0.5–2 ng/mL). The patient reports nausea,
anorexia, and seeing “yellow halos.” After checking the apical pulse and finding it 58 bpm and
irregular, what should the nurse do first?
A) Administer the scheduled digoxin and recheck the pulse in 1 hour
B) Hold digoxin, give potassium supplement, and notify the provider
,C) Prepare to administer digoxin immune Fab immediately
D) Give atropine and monitor for bradycardia
Correct Answer: B
Rationale: The patient shows signs of digoxin toxicity (GI, visual, bradycardia) with hypokalemia,
which potentiates toxicity. The nurse should hold the dose, address the low potassium (as
ordered), and notify the provider. Digoxin immune Fab is used for severe toxicity and is not the
first independent nursing action.
5. A patient with a creatinine clearance of 22 mL/min is prescribed enoxaparin 1 mg/kg
subcutaneously every 12 hours for acute DVT treatment. Which laboratory test is most
important to monitor to ensure safety?
A) aPTT
B) Anti–factor Xa activity
C) PT/INR
D) Serum sodium
Correct Answer: B
Rationale: Enoxaparin, a low-molecular-weight heparin, is renally eliminated and accumulates
in severe renal impairment. Routine monitoring is not required, but in reduced renal function,
anti–factor Xa levels should be measured to guide dosing and prevent bleeding. aPTT is not
reliably affected.
6. During a packed RBC transfusion, the patient develops urticaria, pruritus, and mild wheezing.
Vitals: BP 120/78 mm Hg, HR 92 bpm, RR 22. The nurse identifies which type of transfusion
reaction?
A) Febrile nonhemolytic
B) Allergic
C) Acute hemolytic
D) Transfusion-related acute lung injury (TRALI)
Correct Answer: B
Rationale: Urticaria and wheezing without fever or hypotension indicate an allergic reaction,
usually to plasma proteins in the component. Febrile nonhemolytic causes fever, chills;
hemolytic presents with flank pain, fever, hypotension, dark urine; TRALI causes acute
respiratory distress.
, 7. A postoperative patient rates pain as 7/10. The prescription reads: hydromorphone 0.6 mg IV
push every 3 hours PRN. The pharmacy supplies hydromorphone 2 mg/mL. How many mL
should the nurse administer? (Round to the nearest tenth.)
A) 0.2 mL
B) 0.3 mL
C) 0.5 mL
D) 0.6 mL
Correct Answer: B
Rationale: Desired dose (0.6 mg) divided by concentration (2 mg/mL) = 0.3 mL. Use a 1 mL
syringe for accuracy.
8. A patient with type 1 diabetes uses an insulin pump delivering insulin lispro. She is scheduled
for a 2-hour MRI under sedation and will be NPO. The nurse anticipates which plan?
A) Continue the insulin pump at basal rate with hourly glucose checks
B) Discontinue the pump and administer subcutaneous insulin glargine before the procedure
C) Suspend the pump and start an IV regular insulin infusion
D) Remove the pump and give no insulin until the procedure is over
Correct Answer: A
Rationale: Current guidelines allow insulin pump continuation at basal rate during short NPO
periods with frequent blood glucose monitoring to prevent ketoacidosis. An IV insulin infusion is
indicated for major surgery or prolonged fasting. Suspending without basal coverage risks
ketosis.
9. An order reads: infuse 1 unit of apheresed platelets (250 mL) over 30 minutes. The blood
administration set delivers 10 gtt/mL. Calculate the drip rate in gtt/min. (Round to the nearest
whole number.)
A) 42 gtt/min
B) 63 gtt/min
C) 83 gtt/min
D) 125 gtt/min
Correct Answer: C
Rationale: Volume (250 mL) ÷ time (30 min) = 8.33 mL/min × 10 gtt/mL = 83.3 ≈ 83 gtt/min.
10. A patient on phenytoin reports diplopia and unsteady gait. The serum phenytoin level is 28
mcg/mL (therapeutic 10–20). Which nursing action is priority?
