Mark Klimek Blue Book - NCLEX Questions Update |
Complete Test Bank (2026 Edition) with 2 Versions
1. A patient with acute respiratory distress syndrome (ARDS) is on mechanical ventilation with
FiO 0.8, PEEP 12 cmHO, and a PaO of 55 mm Hg. The nurse receives an order to administer a
neuromuscular blocking agent (cisatracurium). Which finding would contraindicate
administration?
A. Heart rate 110 bpm
B. Blood pressure 85/50 mm Hg
C. Spontaneous respiratory rate 22/min
D. Sedation score -4 on Richmond Agitation-Sedation Scale (RASS)
Answer: B
Rationale: Neuromuscular blockers can worsen hypotension due to histamine release and loss of
sympathetic tone. Hypotension (BP 85/50) must be corrected first. Tachycardia is common in ARDS.
Spontaneous breathing may be suppressed intentionally. RASS -4 indicates deep sedation, which is
appropriate before paralytic administration.
2. A nurse is reviewing laboratory results for a patient with chronic kidney disease (stage 4). Which
finding requires immediate intervention?
A. Serum potassium 5.8 mEq/L
B. Serum calcium 8.9 mg/dL
C. Hemoglobin 9.2 g/dL
D. Serum phosphate 5.0 mg/dL
Answer: A
Rationale: Potassium > 5.5 mEq/L in CKD can cause life-threatening cardiac dysrhythmias. Calcium 8.9
mg/dL is slightly low but not critical. Hemoglobin 9.2 is expected in CKD anemia and managed with
erythropoietin. Phosphate 5.0 is elevated but not immediately dangerous; it requires dietary restriction
and binders.
3. The nurse is caring for a patient with a chest tube connected to a dry suction water seal drainage
system. The suction control chamber shows continuous gentle bubbling, and the water seal
chamber has fluctuation with inspiration. The nurse notes that the drainage system has been
accidentally tipped over. What action should the nurse take first?
A. Clamp the chest tube immediately
B. Reposition the drainage system upright and assess for air leak
C. Increase suction pressure until bubbling resumes
D. Replace the drainage system with a new one
Answer: B
Page 1
,Rationale: Tipping the system may disrupt the water seal. First, return the system to an upright position and assess for
continued fluctuation and absence of air leak. Clamping is dangerous if an air leak is present (tension pneumothorax risk).
Increasing suction does not fix the seal. Replacement is not necessary unless the system is damaged.
4. A nurse is administering IV vancomycin to a patient with methicillin-resistant Staphylococcus
aureus (MRSA) bacteremia. The patient reports sudden onset of flushing, pruritus, and
hypotension. Which nursing action is most appropriate?
A. Slow the infusion rate and administer diphenhydramine
B. Stop the infusion immediately and maintain IV access
C. Flush the IV line with normal saline and continue infusion
D. Administer epinephrine 0.3 mg IM and notify the provider
Answer: B
Rationale: Flushing, pruritus, and hypotension suggest anaphylaxis or Red Man Syndrome (RMS). For
anaphylaxis, the priority is to stop the drug. RMS is infusion-rate related and may be managed by
slowing, but hypotension indicates a severe reaction requiring immediate cessation. Epinephrine is for
anaphylaxis but stopping the infusion is the first step.
5. A patient with a history of bipolar I disorder is admitted in acute mania. The provider orders
lithium carbonate 600 mg PO TID. Which laboratory value is most important for the nurse to
review before administering the first dose?
A. Serum creatinine 1.8 mg/dL
B. Serum sodium 135 mEq/L
C. White blood cell count 12,000/mm³
D. Thyroid-stimulating hormone (TSH) 4.5 mIU/mL
Answer: A
Rationale: Lithium is excreted renally; elevated creatinine (1.8 mg/dL) indicates impaired clearance and
risk of toxicity. Sodium 135 is low normal; hyponatremia increases lithium reabsorption but is less
immediate. WBC elevation is common in mania. TSH elevation may indicate hypothyroidism but does
not contraindicate lithium.
6. The nurse is assessing a patient with a basilar skull fracture. Which finding is most indicative of
this injury?
A. Periorbital ecchymosis (raccoon eyes)
B. Battle's sign over the mastoid process
C. Clear fluid draining from the nose
D. Cerebrospinal fluid (CSF) otorrhea
Answer: C
Rationale: Clear nasal drainage (rhinorrhea) is a classic sign of basilar skull fracture with dural tear
and CSF leak. Raccoon eyes and Battle's sign are also associated but may appear later. Otorrhea
indicates CSF from the ear. However, the question asks for 'most indicative'; clear rhinorrhea is
pathognomonic when confirmed by glucose testing.
Page 2
,7. A nurse is preparing to administer a blood transfusion. The patient's vital signs are: BP 100/60,
HR 95, RR 18, temp 37.0°C. Fifteen minutes after starting the transfusion, the patient develops
chills, headache, and temperature 38.5°C. What is the nurse's priority action?
A. Slow the transfusion rate and administer antipyretics
B. Stop the transfusion and keep the IV line open with normal saline
C. Increase the flow rate to complete the transfusion quickly
D. Administer diphenhydramine and continue transfusion
Answer: B
Rationale: Fever, chills, and headache within 15 minutes indicate a febrile non-hemolytic transfusion
reaction or possible hemolytic reaction. The priority is to stop the transfusion to prevent further
reaction. Slowing or continuing risks worsening. Antipyretics may be given after stopping. Keeping IV
access is essential for emergency medications.
8. The nurse is caring for a patient who had a transurethral resection of the prostate (TURP) with
continuous bladder irrigation. The nurse notes bright red urine with large clots and the drainage is
sluggish. Which action should the nurse take first?
A. Increase the irrigation flow rate
B. Milk the tubing to dislodge clots
C. Notify the surgeon immediately
D. Document the finding as expected
Answer: B
Rationale: Sluggish drainage with clots indicates catheter obstruction. The first action is to manually
irrigate or milk the tubing to restore patency. Increasing flow may worsen distention. Notifying the
surgeon is necessary if manual irrigation fails. Bright red urine with clots is not normal; it indicates
bleeding.
9. A nurse is evaluating a patient's arterial blood gas (ABG) results: pH 7.28, PaCO 50 mm Hg,
HCO 24 mEq/L. Which condition do these values indicate?
A. Metabolic acidosis, uncompensated
B. Respiratory acidosis, uncompensated
C. Metabolic alkalosis, partially compensated
D. Respiratory acidosis, fully compensated
Answer: B
Rationale: pH 7.28 is acidotic. PaCO ‚ 50 is elevated (respiratory acidosis). HCO ƒ { 24 is normal,
indicating no renal compensation. Therefore, it is uncompensated respiratory acidosis. Metabolic
acidosis would show low HCO. Compensation would require HCO > 24.
10. The nurse is teaching a patient with a new diagnosis of type 2 diabetes about self-monitoring of
blood glucose. Which statement by the patient indicates a need for further teaching?
A. I will wash my hands with soap and water before testing
B. I can use the same lancet multiple times if I clean it with alcohol
C. I should rotate sites to prevent calluses
Page 3
, D. I will record my results in a logbook
Answer: B
Rationale: Lancets are single-use to prevent infection and ensure sharpness. Reusing a lancet, even with
alcohol, increases risk of infection and pain. Hand washing, site rotation, and logging are correct
practices.
11. A nurse on a medical-surgical unit is reviewing the laboratory results of a patient with chronic
kidney disease (CKD) stage 4. The patient's serum potassium is 5.8 mEq/L, and the ECG shows
peaked T waves. Which of the following interventions should the nurse anticipate?
A. Administer sodium polystyrene sulfonate orally.
B. Administer intravenous calcium gluconate.
C. Administer intravenous regular insulin with dextrose 50%.
D. Administer albuterol via nebulization.
Answer: B
Rationale: In hyperkalemia with ECG changes (peaked T waves), the priority is to stabilize the cardiac
membrane with IV calcium gluconate. Other options lower potassium but do not address immediate
cardiac risk. Calcium gluconate acts within minutes to antagonize the effects of potassium on the heart.
12. A patient with a history of type 2 diabetes mellitus and hypertension is admitted with acute
kidney injury (AKI) following administration of IV contrast for a CT scan. Which of the following
findings would most strongly support a diagnosis of intrinsic renal AKI rather than prerenal
azotemia?
A. Urine sodium < 10 mEq/L
B. Fractional excretion of sodium (FeNa) < 1%
C. Urine osmolality > 500 mOsm/kg
D. Urine sediment with muddy brown granular casts
Answer: D
Rationale: Muddy brown granular casts are characteristic of acute tubular necrosis (intrinsic AKI).
Prerenal azotemia typically shows low urine sodium, low FeNa, and high urine osmolality due to intact
tubular function. In intrinsic AKI, tubular damage impairs concentrating ability and sodium
reabsorption.
13. A nurse is caring for a patient who is receiving a continuous infusion of heparin for the
treatment of a deep vein thrombosis. The patient's activated partial thromboplastin time (aPTT) is
120 seconds (therapeutic range 60-80 seconds). Which of the following actions should the nurse
take?
A. Increase the infusion rate by 2 units/kg/hr.
B. Decrease the infusion rate by 2 units/kg/hr.
C. Administer protamine sulfate 1 mg per 100 units of heparin estimated in the patient's system.
D. Hold the infusion for 1 hour and then restart at a lower rate.
Answer: D
Rationale: An aPTT of 120 seconds indicates supratherapeutic anticoagulation with risk of bleeding. The
standard protocol is to hold the infusion and restart at a lower rate once aPTT returns to therapeutic
Page 4
Complete Test Bank (2026 Edition) with 2 Versions
1. A patient with acute respiratory distress syndrome (ARDS) is on mechanical ventilation with
FiO 0.8, PEEP 12 cmHO, and a PaO of 55 mm Hg. The nurse receives an order to administer a
neuromuscular blocking agent (cisatracurium). Which finding would contraindicate
administration?
A. Heart rate 110 bpm
B. Blood pressure 85/50 mm Hg
C. Spontaneous respiratory rate 22/min
D. Sedation score -4 on Richmond Agitation-Sedation Scale (RASS)
Answer: B
Rationale: Neuromuscular blockers can worsen hypotension due to histamine release and loss of
sympathetic tone. Hypotension (BP 85/50) must be corrected first. Tachycardia is common in ARDS.
Spontaneous breathing may be suppressed intentionally. RASS -4 indicates deep sedation, which is
appropriate before paralytic administration.
2. A nurse is reviewing laboratory results for a patient with chronic kidney disease (stage 4). Which
finding requires immediate intervention?
A. Serum potassium 5.8 mEq/L
B. Serum calcium 8.9 mg/dL
C. Hemoglobin 9.2 g/dL
D. Serum phosphate 5.0 mg/dL
Answer: A
Rationale: Potassium > 5.5 mEq/L in CKD can cause life-threatening cardiac dysrhythmias. Calcium 8.9
mg/dL is slightly low but not critical. Hemoglobin 9.2 is expected in CKD anemia and managed with
erythropoietin. Phosphate 5.0 is elevated but not immediately dangerous; it requires dietary restriction
and binders.
3. The nurse is caring for a patient with a chest tube connected to a dry suction water seal drainage
system. The suction control chamber shows continuous gentle bubbling, and the water seal
chamber has fluctuation with inspiration. The nurse notes that the drainage system has been
accidentally tipped over. What action should the nurse take first?
A. Clamp the chest tube immediately
B. Reposition the drainage system upright and assess for air leak
C. Increase suction pressure until bubbling resumes
D. Replace the drainage system with a new one
Answer: B
Page 1
,Rationale: Tipping the system may disrupt the water seal. First, return the system to an upright position and assess for
continued fluctuation and absence of air leak. Clamping is dangerous if an air leak is present (tension pneumothorax risk).
Increasing suction does not fix the seal. Replacement is not necessary unless the system is damaged.
4. A nurse is administering IV vancomycin to a patient with methicillin-resistant Staphylococcus
aureus (MRSA) bacteremia. The patient reports sudden onset of flushing, pruritus, and
hypotension. Which nursing action is most appropriate?
A. Slow the infusion rate and administer diphenhydramine
B. Stop the infusion immediately and maintain IV access
C. Flush the IV line with normal saline and continue infusion
D. Administer epinephrine 0.3 mg IM and notify the provider
Answer: B
Rationale: Flushing, pruritus, and hypotension suggest anaphylaxis or Red Man Syndrome (RMS). For
anaphylaxis, the priority is to stop the drug. RMS is infusion-rate related and may be managed by
slowing, but hypotension indicates a severe reaction requiring immediate cessation. Epinephrine is for
anaphylaxis but stopping the infusion is the first step.
5. A patient with a history of bipolar I disorder is admitted in acute mania. The provider orders
lithium carbonate 600 mg PO TID. Which laboratory value is most important for the nurse to
review before administering the first dose?
A. Serum creatinine 1.8 mg/dL
B. Serum sodium 135 mEq/L
C. White blood cell count 12,000/mm³
D. Thyroid-stimulating hormone (TSH) 4.5 mIU/mL
Answer: A
Rationale: Lithium is excreted renally; elevated creatinine (1.8 mg/dL) indicates impaired clearance and
risk of toxicity. Sodium 135 is low normal; hyponatremia increases lithium reabsorption but is less
immediate. WBC elevation is common in mania. TSH elevation may indicate hypothyroidism but does
not contraindicate lithium.
6. The nurse is assessing a patient with a basilar skull fracture. Which finding is most indicative of
this injury?
A. Periorbital ecchymosis (raccoon eyes)
B. Battle's sign over the mastoid process
C. Clear fluid draining from the nose
D. Cerebrospinal fluid (CSF) otorrhea
Answer: C
Rationale: Clear nasal drainage (rhinorrhea) is a classic sign of basilar skull fracture with dural tear
and CSF leak. Raccoon eyes and Battle's sign are also associated but may appear later. Otorrhea
indicates CSF from the ear. However, the question asks for 'most indicative'; clear rhinorrhea is
pathognomonic when confirmed by glucose testing.
Page 2
,7. A nurse is preparing to administer a blood transfusion. The patient's vital signs are: BP 100/60,
HR 95, RR 18, temp 37.0°C. Fifteen minutes after starting the transfusion, the patient develops
chills, headache, and temperature 38.5°C. What is the nurse's priority action?
A. Slow the transfusion rate and administer antipyretics
B. Stop the transfusion and keep the IV line open with normal saline
C. Increase the flow rate to complete the transfusion quickly
D. Administer diphenhydramine and continue transfusion
Answer: B
Rationale: Fever, chills, and headache within 15 minutes indicate a febrile non-hemolytic transfusion
reaction or possible hemolytic reaction. The priority is to stop the transfusion to prevent further
reaction. Slowing or continuing risks worsening. Antipyretics may be given after stopping. Keeping IV
access is essential for emergency medications.
8. The nurse is caring for a patient who had a transurethral resection of the prostate (TURP) with
continuous bladder irrigation. The nurse notes bright red urine with large clots and the drainage is
sluggish. Which action should the nurse take first?
A. Increase the irrigation flow rate
B. Milk the tubing to dislodge clots
C. Notify the surgeon immediately
D. Document the finding as expected
Answer: B
Rationale: Sluggish drainage with clots indicates catheter obstruction. The first action is to manually
irrigate or milk the tubing to restore patency. Increasing flow may worsen distention. Notifying the
surgeon is necessary if manual irrigation fails. Bright red urine with clots is not normal; it indicates
bleeding.
9. A nurse is evaluating a patient's arterial blood gas (ABG) results: pH 7.28, PaCO 50 mm Hg,
HCO 24 mEq/L. Which condition do these values indicate?
A. Metabolic acidosis, uncompensated
B. Respiratory acidosis, uncompensated
C. Metabolic alkalosis, partially compensated
D. Respiratory acidosis, fully compensated
Answer: B
Rationale: pH 7.28 is acidotic. PaCO ‚ 50 is elevated (respiratory acidosis). HCO ƒ { 24 is normal,
indicating no renal compensation. Therefore, it is uncompensated respiratory acidosis. Metabolic
acidosis would show low HCO. Compensation would require HCO > 24.
10. The nurse is teaching a patient with a new diagnosis of type 2 diabetes about self-monitoring of
blood glucose. Which statement by the patient indicates a need for further teaching?
A. I will wash my hands with soap and water before testing
B. I can use the same lancet multiple times if I clean it with alcohol
C. I should rotate sites to prevent calluses
Page 3
, D. I will record my results in a logbook
Answer: B
Rationale: Lancets are single-use to prevent infection and ensure sharpness. Reusing a lancet, even with
alcohol, increases risk of infection and pain. Hand washing, site rotation, and logging are correct
practices.
11. A nurse on a medical-surgical unit is reviewing the laboratory results of a patient with chronic
kidney disease (CKD) stage 4. The patient's serum potassium is 5.8 mEq/L, and the ECG shows
peaked T waves. Which of the following interventions should the nurse anticipate?
A. Administer sodium polystyrene sulfonate orally.
B. Administer intravenous calcium gluconate.
C. Administer intravenous regular insulin with dextrose 50%.
D. Administer albuterol via nebulization.
Answer: B
Rationale: In hyperkalemia with ECG changes (peaked T waves), the priority is to stabilize the cardiac
membrane with IV calcium gluconate. Other options lower potassium but do not address immediate
cardiac risk. Calcium gluconate acts within minutes to antagonize the effects of potassium on the heart.
12. A patient with a history of type 2 diabetes mellitus and hypertension is admitted with acute
kidney injury (AKI) following administration of IV contrast for a CT scan. Which of the following
findings would most strongly support a diagnosis of intrinsic renal AKI rather than prerenal
azotemia?
A. Urine sodium < 10 mEq/L
B. Fractional excretion of sodium (FeNa) < 1%
C. Urine osmolality > 500 mOsm/kg
D. Urine sediment with muddy brown granular casts
Answer: D
Rationale: Muddy brown granular casts are characteristic of acute tubular necrosis (intrinsic AKI).
Prerenal azotemia typically shows low urine sodium, low FeNa, and high urine osmolality due to intact
tubular function. In intrinsic AKI, tubular damage impairs concentrating ability and sodium
reabsorption.
13. A nurse is caring for a patient who is receiving a continuous infusion of heparin for the
treatment of a deep vein thrombosis. The patient's activated partial thromboplastin time (aPTT) is
120 seconds (therapeutic range 60-80 seconds). Which of the following actions should the nurse
take?
A. Increase the infusion rate by 2 units/kg/hr.
B. Decrease the infusion rate by 2 units/kg/hr.
C. Administer protamine sulfate 1 mg per 100 units of heparin estimated in the patient's system.
D. Hold the infusion for 1 hour and then restart at a lower rate.
Answer: D
Rationale: An aPTT of 120 seconds indicates supratherapeutic anticoagulation with risk of bleeding. The
standard protocol is to hold the infusion and restart at a lower rate once aPTT returns to therapeutic
Page 4
