ADVANCED CLINICAL NURSING LICENSURE &
COMPETENCY EXAM
200 Comprehensive NCLEX-Style Clinical Judgment Questions with
Full Rationales
Covering Acute Care, Pediatrics, Pharmacology, Critical Care, Mental
Health, and Leadership
Question 1 (Pediatrics & Hematology / Transfusion Safety)
A nurse is evaluating a school-age child who is receiving a blood
transfusion and develops restlessness, low back pain, and chills. Which
of the following actions should the nurse take first?
A) Notify the primary healthcare provider immediately.
B) Administer diphenhydramine as prescribed.
C) Stop the blood transfusion immediately.
D) Flush the intravenous line with 0.9% sodium chloride.
Correct Answer: C) Stop the blood transfusion immediately.
Rationale: The immediate priority when a transfusion reaction (such
as an acute hemolytic reaction manifested by restlessness, low back
pain, and chills) is suspected is to stop the transfusion immediately to
halt further antigen-antibody reaction. Next, the nurse disconnects the
tubing, infuses 0.9% sodium chloride through a new set of tubing to
maintain venous access, notifies the provider, and sends the blood bag
and remaining contents to the laboratory.
Question 2 (Pharmacology & Parenteral Therapy)
,[Pharmacology & Parenteral Therapy - Item 2] A client with chronic
kidney disease (CKD) has a serum potassium level of 6.2 mEq/L. Which
of the following medications should the nurse anticipate administering
first to shift potassium intracellularly?
A) Oral sodium polystyrene sulfonate
B) Regular insulin with 50% dextrose IV
C) Intravenous calcium gluconate
D) Oral furosemide
Correct Answer: B) Regular insulin with 50% dextrose IV
Rationale: Regular insulin shifts potassium into the cells within 30
minutes, lowering serum levels rapidly. Glucose is administered
concurrently to prevent severe hypoglycemia. Calcium gluconate
protects the myocardium from arrhythmias but does not lower
potassium levels; sodium polystyrene sulfonate works slowly via the
GI tract.
Question 3 (Pediatric Nursing & Growth)
[Pediatric Nursing & Growth - Item 3] A nurse is caring for a client
admitted with diabetic ketoacidosis (DKA). Which of the following
arterial blood gas (ABG) results should the nurse expect?
A) pH 7.48, PaCO2 38 mmHg, HCO3 28 mEq/L
B) pH 7.30, PaCO2 32 mmHg, HCO3 14 mEq/L
C) pH 7.50, PaCO2 48 mmHg, HCO3 30 mEq/L
D) pH 7.28, PaCO2 50 mmHg, HCO3 24 mEq/L
Correct Answer: B) pH 7.30, PaCO2 32 mmHg, HCO3 14 mEq/L
Rationale: DKA is characterized by metabolic acidosis resulting from
ketoacid accumulation, reflected by a low pH (< 7.35) and low
,bicarbonate (< 22 mEq/L). The respiratory system compensates by
hyperventilating (Kussmaul respirations), leading to a decreased
PaCO2.
Question 4 (Maternal-Newborn & Women's Health)
[Maternal-Newborn & Women's Health - Item 4] A nurse is assessing a
client 4 hours following a thyroidectomy. The client exhibits muscle
twitching, numbness around the mouth, and positive Trousseau's sign.
Which of the following medications should the nurse have readily
available?
A) Naloxone hydrochloride
B) Calcium gluconate
C) Protamine sulfate
D) Potassium chloride
Correct Answer: B) Calcium gluconate
Rationale: Postoperative thyroidectomy clients are at risk for
hypocalcemia and tetany due to inadvertent removal of or trauma to
the parathyroid glands. Calcium gluconate is the specific
antidote/replacement therapy for acute hypocalcemic tetany.
Question 5 (Mental Health & Psychiatric Nursing)
[Mental Health & Psychiatric Nursing - Item 5] A nurse is providing
discharge instructions to a client prescribed warfarin. Which of the
following client statements indicates a need for further teaching?
A) 'I will use an electric razor when shaving.'
B) 'I should keep my intake of green leafy vegetables consistent from
day to day.'
, C) 'I will take aspirin for mild headaches.'
D) 'I will have my blood tested regularly for INR.'
Correct Answer: C) 'I will take aspirin for mild headaches.'
Rationale: Aspirin inhibits platelet aggregation and increases the risk
of severe bleeding when taken concurrently with warfarin. Clients
taking warfarin should avoid NSAIDs, aspirin, and salicylate
products, using acetaminophen instead as prescribed.
Question 6 (Leadership, Management, & Legal Ethics)
[Leadership, Management, & Legal Ethics - Item 6] A nurse in the
emergency department receives a client who experienced severe chest
pain beginning 2 hours ago. Which of the following cardiac markers is
the most specific and early indicator of myocardial injury?
A) Creatine kinase-MB (CK-MB)
B) Myoglobin
C) Troponin T
D) C-reactive protein
Correct Answer: C) Troponin T
Rationale: Cardiac troponins (Troponin I and Troponin T) are highly
specific and sensitive markers for myocardial necrosis, rising within 3
to 4 hours and remaining elevated for up to 3 weeks. Myoglobin rises
earlier but lacks cardiac specificity.
Question 7 (Medical-Surgical & Critical Care)
[Medical-Surgical & Critical Care - Item 7] A nurse is monitoring a
client receiving an intravenous infusion of heparin sodium for deep vein
COMPETENCY EXAM
200 Comprehensive NCLEX-Style Clinical Judgment Questions with
Full Rationales
Covering Acute Care, Pediatrics, Pharmacology, Critical Care, Mental
Health, and Leadership
Question 1 (Pediatrics & Hematology / Transfusion Safety)
A nurse is evaluating a school-age child who is receiving a blood
transfusion and develops restlessness, low back pain, and chills. Which
of the following actions should the nurse take first?
A) Notify the primary healthcare provider immediately.
B) Administer diphenhydramine as prescribed.
C) Stop the blood transfusion immediately.
D) Flush the intravenous line with 0.9% sodium chloride.
Correct Answer: C) Stop the blood transfusion immediately.
Rationale: The immediate priority when a transfusion reaction (such
as an acute hemolytic reaction manifested by restlessness, low back
pain, and chills) is suspected is to stop the transfusion immediately to
halt further antigen-antibody reaction. Next, the nurse disconnects the
tubing, infuses 0.9% sodium chloride through a new set of tubing to
maintain venous access, notifies the provider, and sends the blood bag
and remaining contents to the laboratory.
Question 2 (Pharmacology & Parenteral Therapy)
,[Pharmacology & Parenteral Therapy - Item 2] A client with chronic
kidney disease (CKD) has a serum potassium level of 6.2 mEq/L. Which
of the following medications should the nurse anticipate administering
first to shift potassium intracellularly?
A) Oral sodium polystyrene sulfonate
B) Regular insulin with 50% dextrose IV
C) Intravenous calcium gluconate
D) Oral furosemide
Correct Answer: B) Regular insulin with 50% dextrose IV
Rationale: Regular insulin shifts potassium into the cells within 30
minutes, lowering serum levels rapidly. Glucose is administered
concurrently to prevent severe hypoglycemia. Calcium gluconate
protects the myocardium from arrhythmias but does not lower
potassium levels; sodium polystyrene sulfonate works slowly via the
GI tract.
Question 3 (Pediatric Nursing & Growth)
[Pediatric Nursing & Growth - Item 3] A nurse is caring for a client
admitted with diabetic ketoacidosis (DKA). Which of the following
arterial blood gas (ABG) results should the nurse expect?
A) pH 7.48, PaCO2 38 mmHg, HCO3 28 mEq/L
B) pH 7.30, PaCO2 32 mmHg, HCO3 14 mEq/L
C) pH 7.50, PaCO2 48 mmHg, HCO3 30 mEq/L
D) pH 7.28, PaCO2 50 mmHg, HCO3 24 mEq/L
Correct Answer: B) pH 7.30, PaCO2 32 mmHg, HCO3 14 mEq/L
Rationale: DKA is characterized by metabolic acidosis resulting from
ketoacid accumulation, reflected by a low pH (< 7.35) and low
,bicarbonate (< 22 mEq/L). The respiratory system compensates by
hyperventilating (Kussmaul respirations), leading to a decreased
PaCO2.
Question 4 (Maternal-Newborn & Women's Health)
[Maternal-Newborn & Women's Health - Item 4] A nurse is assessing a
client 4 hours following a thyroidectomy. The client exhibits muscle
twitching, numbness around the mouth, and positive Trousseau's sign.
Which of the following medications should the nurse have readily
available?
A) Naloxone hydrochloride
B) Calcium gluconate
C) Protamine sulfate
D) Potassium chloride
Correct Answer: B) Calcium gluconate
Rationale: Postoperative thyroidectomy clients are at risk for
hypocalcemia and tetany due to inadvertent removal of or trauma to
the parathyroid glands. Calcium gluconate is the specific
antidote/replacement therapy for acute hypocalcemic tetany.
Question 5 (Mental Health & Psychiatric Nursing)
[Mental Health & Psychiatric Nursing - Item 5] A nurse is providing
discharge instructions to a client prescribed warfarin. Which of the
following client statements indicates a need for further teaching?
A) 'I will use an electric razor when shaving.'
B) 'I should keep my intake of green leafy vegetables consistent from
day to day.'
, C) 'I will take aspirin for mild headaches.'
D) 'I will have my blood tested regularly for INR.'
Correct Answer: C) 'I will take aspirin for mild headaches.'
Rationale: Aspirin inhibits platelet aggregation and increases the risk
of severe bleeding when taken concurrently with warfarin. Clients
taking warfarin should avoid NSAIDs, aspirin, and salicylate
products, using acetaminophen instead as prescribed.
Question 6 (Leadership, Management, & Legal Ethics)
[Leadership, Management, & Legal Ethics - Item 6] A nurse in the
emergency department receives a client who experienced severe chest
pain beginning 2 hours ago. Which of the following cardiac markers is
the most specific and early indicator of myocardial injury?
A) Creatine kinase-MB (CK-MB)
B) Myoglobin
C) Troponin T
D) C-reactive protein
Correct Answer: C) Troponin T
Rationale: Cardiac troponins (Troponin I and Troponin T) are highly
specific and sensitive markers for myocardial necrosis, rising within 3
to 4 hours and remaining elevated for up to 3 weeks. Myoglobin rises
earlier but lacks cardiac specificity.
Question 7 (Medical-Surgical & Critical Care)
[Medical-Surgical & Critical Care - Item 7] A nurse is monitoring a
client receiving an intravenous infusion of heparin sodium for deep vein
