NCLEX-RN® Comprehensive Examination
Practice Questions a well detailed exam
2025/2026 graded A+ upgraded !!! Version
3.1 | Advanced/Hard/Difficult | 150
Multiple-Choice Questions with Detailed
Complicated Rationales
SECTION 1: SAFE AND EFFECTIVE CARE ENVIRONMENT — Management of Care (Questions 1-
25)
Question 1
A charge nurse is evaluating a newly implemented rapid response team (RRT) protocol on a
medical-surgical unit. The protocol uses specific criteria for activation including acute changes in
heart rate (< 40 or > 130 bpm), respiratory rate (< 8 or > 28 breaths/min), systolic blood
pressure (< 90 mmHg), oxygen saturation (< 90% despite supplemental oxygen), acute change in
mental status, or staff concern. Over the past three months, RRT activations have increased by
40%, but cardiac arrests on the unit have decreased by 25%. Which interpretation of this data is
most accurate?
A. The RRT protocol is ineffective because activations have increased
B. The RRT protocol is effective because earlier intervention is preventing deterioration
C. The RRT protocol needs revision because criteria are too sensitive
D. The data is inconclusive and requires further analysis
,Correct Answer: B
Rationale: The increase in RRT activations combined with a decrease in cardiac arrests indicates
that the protocol is working as intended—early identification and intervention are preventing
patient deterioration and cardiac arrest. Option A misinterprets increased activations as failure.
Option C: Increased activations with improved outcomes suggest appropriate sensitivity. Option
D: The data shows a clear correlation that supports effectiveness, though continued monitoring
is warranted.
Question 2
A nurse is caring for a 78-year-old patient with end-stage chronic obstructive pulmonary disease
(COPD) who has a valid physician orders for life-sustaining treatment (POLST) form indicating
"comfort measures only." The patient's adult daughter, who holds durable power of attorney for
healthcare, arrives at the hospital and demands that the patient be intubated and transferred to
the intensive care unit because "my mother is a fighter and would want everything done." The
patient is alert and oriented, and when asked, shakes her head "no" vigorously. What is the
nurse's priority action?
A. Contact the hospital ethics committee to review the conflict
B. Respect the daughter's wishes as the legal surrogate decision-maker
C. Respect the patient's wishes and document the patient's refusal
D. Notify the healthcare provider to discuss the conflict with the daughter
Correct Answer: C
Rationale: An alert, oriented patient has the right to make their own healthcare decisions, and
the POLST form documents those wishes. The surrogate's authority only applies when the
patient lacks decision-making capacity. The nurse should advocate for the patient's autonomy.
Option A: Ethics committee consultation is premature. Option B: Violates the patient's
autonomy. Option D: While provider notification may be needed, the priority is to respect and
document the patient's wishes.
Question 3
A charge nurse is making assignments for a 40-bed medical-surgical unit. The following staff are
available: one RN with 15 years of experience who works night shift regularly, one RN with 3
years of experience, one RN in her second week of orientation, one new graduate RN who
completed orientation 2 weeks ago, one licensed practical nurse (LPN) with 10 years of
,experience, and two unlicensed assistive personnel (UAP). The patient census includes: a
patient with a new tracheostomy requiring frequent suctioning, a patient receiving IV heparin
for a pulmonary embolism, a patient with a hip fracture in Buck's traction, a patient with newly
diagnosed diabetes mellitus requiring insulin teaching, a patient with end-stage renal disease
receiving peritoneal dialysis, a patient with a chest tube following a pneumothorax, and three
stable post-operative patients. Which assignment is most appropriate for patient safety and
staff competency?
A. Assign the patient with the chest tube to the new graduate RN and the patient with the
tracheostomy to the LPN
B. Assign the patient receiving IV heparin to the RN on orientation and the patient with diabetes
to the new graduate RN
C. Assign the peritoneal dialysis patient to the experienced RN and the patient with the chest
tube to the RN with 3 years of experience
D. Assign the patient with the tracheostomy to the experienced RN, the peritoneal dialysis
patient to the RN with 3 years of experience, and the diabetes teaching to the new graduate RN
Correct Answer: D
Rationale: This assignment appropriately matches patient acuity with staff competency and
experience. The most complex patients (tracheostomy, peritoneal dialysis) are assigned to the
most experienced RNs. The diabetes teaching, while important, is appropriate for the new
graduate RN who has completed orientation. Option A: Assigning a chest tube to a new
graduate is unsafe. Option B: IV heparin to an orientee is unsafe. Option C: The RN with 3 years
may not have peritoneal dialysis competency; the experienced RN should manage that patient.
Question 4
A nurse manager is implementing a new evidence-based practice protocol for prevention of
catheter-associated urinary tract infections (CAUTIs). The protocol includes: (1) nurse-initiated
removal of indwelling catheters when no longer indicated using a daily checklist, (2) use of
ultrasound bladder scanners to assess for urinary retention before catheterization, and (3) use
of external condom catheters for male patients without urinary retention. After 6 months of
implementation, CAUTI rates have decreased from 5.2 per 1000 catheter-days to 2.8 per 1000
catheter-days. However, the nurse manager notes an increase in the number of patients with
urinary retention requiring intermittent catheterization. What is the most appropriate action for
the nurse manager?
A. Discontinue the protocol because of the increased intermittent catheterization rate
B. Modify the protocol to include a specific bladder volume threshold for catheter reinsertion
, C. Continue the protocol unchanged because CAUTI rates have decreased
D. Conduct a root cause analysis to determine why intermittent catheterization has increased
Correct Answer: B
Rationale: While CAUTI rates have improved, the increase in intermittent catheterizations
suggests a gap in the protocol. Modifying the protocol to include specific, evidence-based
bladder volume thresholds (e.g., 300-500 mL with symptoms) would maintain the benefits of
early catheter removal while preventing unnecessary intermittent catheterizations. Option A:
Abandoning a successful protocol is inappropriate. Option C: Ignoring the new problem is
insufficient. Option D: Root cause analysis may be helpful but the protocol modification
addresses the issue directly.
Question 5
A nurse is caring for a patient who has been hospitalized for 2 weeks with a complex wound
infection requiring multiple antibiotics and daily wound debridement. The patient is a 45-year-
old mother of three children who has been unable to work during her hospitalization. The
patient states, "I can't take this anymore. I want to leave. Just sign me out." The patient has
decision-making capacity and understands the risks of leaving against medical advice (AMA).
What is the nurse's priority action?
A. Notify the healthcare provider immediately and prepare the AMA discharge paperwork
B. Tell the patient she cannot leave because it would be unsafe
C. Explore the patient's concerns about hospitalization and address barriers to staying
D. Call security to prevent the patient from leaving
Correct Answer: C
Rationale: The nurse should explore the patient's concerns and address barriers to staying in
the hospital. Financial concerns, childcare, and work obligations may be addressed through
social work consultation. The patient has the right to leave AMA if they choose, but the nurse
should first attempt to address underlying concerns. Option A: Premature without exploring
concerns. Option B: False and violates patient rights. Option D: Restraining a patient with
decision-making capacity is illegal.
Question 6
A charge nurse is evaluating the effectiveness of a new medication administration safety
protocol that includes: (1) bar code scanning of patient identification bands and medications,
Practice Questions a well detailed exam
2025/2026 graded A+ upgraded !!! Version
3.1 | Advanced/Hard/Difficult | 150
Multiple-Choice Questions with Detailed
Complicated Rationales
SECTION 1: SAFE AND EFFECTIVE CARE ENVIRONMENT — Management of Care (Questions 1-
25)
Question 1
A charge nurse is evaluating a newly implemented rapid response team (RRT) protocol on a
medical-surgical unit. The protocol uses specific criteria for activation including acute changes in
heart rate (< 40 or > 130 bpm), respiratory rate (< 8 or > 28 breaths/min), systolic blood
pressure (< 90 mmHg), oxygen saturation (< 90% despite supplemental oxygen), acute change in
mental status, or staff concern. Over the past three months, RRT activations have increased by
40%, but cardiac arrests on the unit have decreased by 25%. Which interpretation of this data is
most accurate?
A. The RRT protocol is ineffective because activations have increased
B. The RRT protocol is effective because earlier intervention is preventing deterioration
C. The RRT protocol needs revision because criteria are too sensitive
D. The data is inconclusive and requires further analysis
,Correct Answer: B
Rationale: The increase in RRT activations combined with a decrease in cardiac arrests indicates
that the protocol is working as intended—early identification and intervention are preventing
patient deterioration and cardiac arrest. Option A misinterprets increased activations as failure.
Option C: Increased activations with improved outcomes suggest appropriate sensitivity. Option
D: The data shows a clear correlation that supports effectiveness, though continued monitoring
is warranted.
Question 2
A nurse is caring for a 78-year-old patient with end-stage chronic obstructive pulmonary disease
(COPD) who has a valid physician orders for life-sustaining treatment (POLST) form indicating
"comfort measures only." The patient's adult daughter, who holds durable power of attorney for
healthcare, arrives at the hospital and demands that the patient be intubated and transferred to
the intensive care unit because "my mother is a fighter and would want everything done." The
patient is alert and oriented, and when asked, shakes her head "no" vigorously. What is the
nurse's priority action?
A. Contact the hospital ethics committee to review the conflict
B. Respect the daughter's wishes as the legal surrogate decision-maker
C. Respect the patient's wishes and document the patient's refusal
D. Notify the healthcare provider to discuss the conflict with the daughter
Correct Answer: C
Rationale: An alert, oriented patient has the right to make their own healthcare decisions, and
the POLST form documents those wishes. The surrogate's authority only applies when the
patient lacks decision-making capacity. The nurse should advocate for the patient's autonomy.
Option A: Ethics committee consultation is premature. Option B: Violates the patient's
autonomy. Option D: While provider notification may be needed, the priority is to respect and
document the patient's wishes.
Question 3
A charge nurse is making assignments for a 40-bed medical-surgical unit. The following staff are
available: one RN with 15 years of experience who works night shift regularly, one RN with 3
years of experience, one RN in her second week of orientation, one new graduate RN who
completed orientation 2 weeks ago, one licensed practical nurse (LPN) with 10 years of
,experience, and two unlicensed assistive personnel (UAP). The patient census includes: a
patient with a new tracheostomy requiring frequent suctioning, a patient receiving IV heparin
for a pulmonary embolism, a patient with a hip fracture in Buck's traction, a patient with newly
diagnosed diabetes mellitus requiring insulin teaching, a patient with end-stage renal disease
receiving peritoneal dialysis, a patient with a chest tube following a pneumothorax, and three
stable post-operative patients. Which assignment is most appropriate for patient safety and
staff competency?
A. Assign the patient with the chest tube to the new graduate RN and the patient with the
tracheostomy to the LPN
B. Assign the patient receiving IV heparin to the RN on orientation and the patient with diabetes
to the new graduate RN
C. Assign the peritoneal dialysis patient to the experienced RN and the patient with the chest
tube to the RN with 3 years of experience
D. Assign the patient with the tracheostomy to the experienced RN, the peritoneal dialysis
patient to the RN with 3 years of experience, and the diabetes teaching to the new graduate RN
Correct Answer: D
Rationale: This assignment appropriately matches patient acuity with staff competency and
experience. The most complex patients (tracheostomy, peritoneal dialysis) are assigned to the
most experienced RNs. The diabetes teaching, while important, is appropriate for the new
graduate RN who has completed orientation. Option A: Assigning a chest tube to a new
graduate is unsafe. Option B: IV heparin to an orientee is unsafe. Option C: The RN with 3 years
may not have peritoneal dialysis competency; the experienced RN should manage that patient.
Question 4
A nurse manager is implementing a new evidence-based practice protocol for prevention of
catheter-associated urinary tract infections (CAUTIs). The protocol includes: (1) nurse-initiated
removal of indwelling catheters when no longer indicated using a daily checklist, (2) use of
ultrasound bladder scanners to assess for urinary retention before catheterization, and (3) use
of external condom catheters for male patients without urinary retention. After 6 months of
implementation, CAUTI rates have decreased from 5.2 per 1000 catheter-days to 2.8 per 1000
catheter-days. However, the nurse manager notes an increase in the number of patients with
urinary retention requiring intermittent catheterization. What is the most appropriate action for
the nurse manager?
A. Discontinue the protocol because of the increased intermittent catheterization rate
B. Modify the protocol to include a specific bladder volume threshold for catheter reinsertion
, C. Continue the protocol unchanged because CAUTI rates have decreased
D. Conduct a root cause analysis to determine why intermittent catheterization has increased
Correct Answer: B
Rationale: While CAUTI rates have improved, the increase in intermittent catheterizations
suggests a gap in the protocol. Modifying the protocol to include specific, evidence-based
bladder volume thresholds (e.g., 300-500 mL with symptoms) would maintain the benefits of
early catheter removal while preventing unnecessary intermittent catheterizations. Option A:
Abandoning a successful protocol is inappropriate. Option C: Ignoring the new problem is
insufficient. Option D: Root cause analysis may be helpful but the protocol modification
addresses the issue directly.
Question 5
A nurse is caring for a patient who has been hospitalized for 2 weeks with a complex wound
infection requiring multiple antibiotics and daily wound debridement. The patient is a 45-year-
old mother of three children who has been unable to work during her hospitalization. The
patient states, "I can't take this anymore. I want to leave. Just sign me out." The patient has
decision-making capacity and understands the risks of leaving against medical advice (AMA).
What is the nurse's priority action?
A. Notify the healthcare provider immediately and prepare the AMA discharge paperwork
B. Tell the patient she cannot leave because it would be unsafe
C. Explore the patient's concerns about hospitalization and address barriers to staying
D. Call security to prevent the patient from leaving
Correct Answer: C
Rationale: The nurse should explore the patient's concerns and address barriers to staying in
the hospital. Financial concerns, childcare, and work obligations may be addressed through
social work consultation. The patient has the right to leave AMA if they choose, but the nurse
should first attempt to address underlying concerns. Option A: Premature without exploring
concerns. Option B: False and violates patient rights. Option D: Restraining a patient with
decision-making capacity is illegal.
Question 6
A charge nurse is evaluating the effectiveness of a new medication administration safety
protocol that includes: (1) bar code scanning of patient identification bands and medications,
