NGN HESI RN PHARMACOLOGY REAL EXAM – VERSION C
(2026/2027) 100% Correct Answers with Rationales | Graded
A+ | Unique to Version C
EXAMINATION OVERVIEW
This examination consists of 55 questions designed to assess clinical judgment in
pharmacological nursing practice. The exam includes traditional multiple-choice
questions and Next Generation NCLEX (NGN) item types: Multiple-Select, Matrix/Grid,
Cloze (Drop-Down), and Extended Drag-and-Drop/Ordered Response.
Time Allotment: 120 minutes
Passing Standard: Clinical judgment demonstration across all pharmacology domains
SECTION 1: TRADITIONAL SINGLE-ANSWER MULTIPLE CHOICE QUESTIONS
(Questions 1-37)
Question 1 - Traditional MCQ
A 68-year-old patient with acute decompensated heart failure is receiving a continuous
infusion of milrinone at 0.5 mcg/kg/min. The patient's current vital signs are: BP 88/52
mmHg, HR 112 bpm, RR 24/min. Which assessment finding requires the most
immediate intervention by the nurse?
A) Urine output of 35 mL/hour
,B) Serum potassium of 3.2 mEq/L
C) Presence of ventricular ectopy on cardiac monitor
D) Mild headache reported by the patient
Correct Answer: C
Rationale: Milrinone is a phosphodiesterase-3 inhibitor that increases cardiac
contractility and causes vasodilation. While all options require attention, ventricular
ectopy is the most immediately life-threatening finding. Milrinone can cause serious
ventricular arrhythmias due to its mechanism of increasing intracellular calcium and
cAMP. The patient's borderline hypotension (88/52 mmHg) combined with tachycardia
suggests possible hypoperfusion, creating an arrhythmogenic environment. Option A
(35 mL/hr urine output) is adequate (>0.5 mL/kg/hr for most adults). Option B (K+ 3.2
mEq/L) requires correction but is not immediately life-threatening. Option D (headache)
is a common side effect of vasodilation but not emergent.
Question 2 - Traditional MCQ
A patient with type 2 diabetes and chronic kidney disease (eGFR 28 mL/min/1.73m²) is
prescribed metformin 1000 mg twice daily. Which laboratory value would most strongly
contraindicate the administration of the next scheduled dose?
A) Fasting blood glucose 142 mg/dL
B) Serum creatinine 2.8 mg/dL (baseline 2.6 mg/dL)
C) Arterial blood pH 7.32
D) Hemoglobin A1c 8.2%
,Correct Answer: C
Rationale: Metformin-associated lactic acidosis (MALA) is a rare but potentially fatal
complication. An arterial pH of 7.32 indicates acidemia (normal 7.35-7.45), which
significantly increases the risk of lactic acidosis accumulation because metformin is
excreted unchanged by the kidneys and can accumulate in states of hypoperfusion or
acidosis. The FDA has removed the specific creatinine cutoff (previously >1.5 mg/dL for
men, >1.4 mg/dL for women), now emphasizing eGFR <30 mL/min as a
contraindication. While option B shows worsening renal function, the acidemia in option
C represents an acute metabolic emergency that requires immediate metformin
discontinuation. Option A indicates suboptimal glycemic control but doesn't
contraindicate administration. Option D reflects long-term control but doesn't impact
immediate safety.
Question 3 - Traditional MCQ
A nurse is caring for a patient who received tissue plasminogen activator (tPA) 90
minutes ago for acute ischemic stroke. The patient suddenly develops severe headache,
vomiting, and decreased level of consciousness. What is the nurse's priority action?
A) Position the patient in high Fowler's position
B) Prepare to administer protamine sulfate
C) Obtain a STAT non-contrast CT scan of the head
D) Insert a nasogastric tube for gastric decompression
Correct Answer: C
, Rationale: The presentation of severe headache, vomiting, and decreased LOC 90
minutes post-tPA administration is highly suggestive of intracranial hemorrhage, the
most feared complication of thrombolytic therapy. The priority action is to obtain
immediate neuroimaging to confirm or rule out hemorrhagic transformation. Option A
(high Fowler's) is inappropriate for a patient with suspected increased intracranial
pressure and potential herniation risk. Option B (protamine sulfate) reverses heparin,
not tPA—there is no specific antidote for tPA. Option D (NG tube insertion) is
contraindicated with suspected intracranial hemorrhage due to potential vagal
stimulation and is not the priority. Time is critical: every minute of unrecognized
hemorrhage increases morbidity and mortality.
Question 4 - Traditional MCQ
A patient with septic shock is receiving norepinephrine at 0.5 mcg/kg/min with a MAP
of 58 mmHg. The nurse notes the patient's hands and feet are mottled and cool, while
the core temperature is 38.9°C. Which pathophysiological principle explains this clinical
presentation?
A) Peripheral vasoconstriction shunting blood to vital organs
B) Anaphylactic reaction to the norepinephrine
C) Cardiogenic shock with peripheral cyanosis
D) Distributive shock with inappropriate vasodilation
Correct Answer: A
Rationale: This presentation demonstrates compensatory peripheral vasoconstriction in
septic shock. Despite being a "distributive" shock characterized by pathological
vasodilation, the body—and exogenous norepinephrine—attempts to maintain perfusion
(2026/2027) 100% Correct Answers with Rationales | Graded
A+ | Unique to Version C
EXAMINATION OVERVIEW
This examination consists of 55 questions designed to assess clinical judgment in
pharmacological nursing practice. The exam includes traditional multiple-choice
questions and Next Generation NCLEX (NGN) item types: Multiple-Select, Matrix/Grid,
Cloze (Drop-Down), and Extended Drag-and-Drop/Ordered Response.
Time Allotment: 120 minutes
Passing Standard: Clinical judgment demonstration across all pharmacology domains
SECTION 1: TRADITIONAL SINGLE-ANSWER MULTIPLE CHOICE QUESTIONS
(Questions 1-37)
Question 1 - Traditional MCQ
A 68-year-old patient with acute decompensated heart failure is receiving a continuous
infusion of milrinone at 0.5 mcg/kg/min. The patient's current vital signs are: BP 88/52
mmHg, HR 112 bpm, RR 24/min. Which assessment finding requires the most
immediate intervention by the nurse?
A) Urine output of 35 mL/hour
,B) Serum potassium of 3.2 mEq/L
C) Presence of ventricular ectopy on cardiac monitor
D) Mild headache reported by the patient
Correct Answer: C
Rationale: Milrinone is a phosphodiesterase-3 inhibitor that increases cardiac
contractility and causes vasodilation. While all options require attention, ventricular
ectopy is the most immediately life-threatening finding. Milrinone can cause serious
ventricular arrhythmias due to its mechanism of increasing intracellular calcium and
cAMP. The patient's borderline hypotension (88/52 mmHg) combined with tachycardia
suggests possible hypoperfusion, creating an arrhythmogenic environment. Option A
(35 mL/hr urine output) is adequate (>0.5 mL/kg/hr for most adults). Option B (K+ 3.2
mEq/L) requires correction but is not immediately life-threatening. Option D (headache)
is a common side effect of vasodilation but not emergent.
Question 2 - Traditional MCQ
A patient with type 2 diabetes and chronic kidney disease (eGFR 28 mL/min/1.73m²) is
prescribed metformin 1000 mg twice daily. Which laboratory value would most strongly
contraindicate the administration of the next scheduled dose?
A) Fasting blood glucose 142 mg/dL
B) Serum creatinine 2.8 mg/dL (baseline 2.6 mg/dL)
C) Arterial blood pH 7.32
D) Hemoglobin A1c 8.2%
,Correct Answer: C
Rationale: Metformin-associated lactic acidosis (MALA) is a rare but potentially fatal
complication. An arterial pH of 7.32 indicates acidemia (normal 7.35-7.45), which
significantly increases the risk of lactic acidosis accumulation because metformin is
excreted unchanged by the kidneys and can accumulate in states of hypoperfusion or
acidosis. The FDA has removed the specific creatinine cutoff (previously >1.5 mg/dL for
men, >1.4 mg/dL for women), now emphasizing eGFR <30 mL/min as a
contraindication. While option B shows worsening renal function, the acidemia in option
C represents an acute metabolic emergency that requires immediate metformin
discontinuation. Option A indicates suboptimal glycemic control but doesn't
contraindicate administration. Option D reflects long-term control but doesn't impact
immediate safety.
Question 3 - Traditional MCQ
A nurse is caring for a patient who received tissue plasminogen activator (tPA) 90
minutes ago for acute ischemic stroke. The patient suddenly develops severe headache,
vomiting, and decreased level of consciousness. What is the nurse's priority action?
A) Position the patient in high Fowler's position
B) Prepare to administer protamine sulfate
C) Obtain a STAT non-contrast CT scan of the head
D) Insert a nasogastric tube for gastric decompression
Correct Answer: C
, Rationale: The presentation of severe headache, vomiting, and decreased LOC 90
minutes post-tPA administration is highly suggestive of intracranial hemorrhage, the
most feared complication of thrombolytic therapy. The priority action is to obtain
immediate neuroimaging to confirm or rule out hemorrhagic transformation. Option A
(high Fowler's) is inappropriate for a patient with suspected increased intracranial
pressure and potential herniation risk. Option B (protamine sulfate) reverses heparin,
not tPA—there is no specific antidote for tPA. Option D (NG tube insertion) is
contraindicated with suspected intracranial hemorrhage due to potential vagal
stimulation and is not the priority. Time is critical: every minute of unrecognized
hemorrhage increases morbidity and mortality.
Question 4 - Traditional MCQ
A patient with septic shock is receiving norepinephrine at 0.5 mcg/kg/min with a MAP
of 58 mmHg. The nurse notes the patient's hands and feet are mottled and cool, while
the core temperature is 38.9°C. Which pathophysiological principle explains this clinical
presentation?
A) Peripheral vasoconstriction shunting blood to vital organs
B) Anaphylactic reaction to the norepinephrine
C) Cardiogenic shock with peripheral cyanosis
D) Distributive shock with inappropriate vasodilation
Correct Answer: A
Rationale: This presentation demonstrates compensatory peripheral vasoconstriction in
septic shock. Despite being a "distributive" shock characterized by pathological
vasodilation, the body—and exogenous norepinephrine—attempts to maintain perfusion
