NCLEX-RN 2025 Mega Pack: Next
Generation Real Exam Questions
Latest Edition - Updated November 2025
SECTION 1: NEXT GENERATION ITEM TYPES -
CLINICAL JUDGMENT
Question 1: Extended Multiple Response (Select All That Apply)
A nurse is caring for a 68-year-old client admitted with heart failure exacerbation. Current vital
signs: BP 88/54 mmHg, HR 118 bpm, RR 28/min, SpO2 89% on room air, temp 98.6°F. The
client reports severe shortness of breath and anxiety. Which actions should the nurse take?
(Select all that apply)
A. Administer prescribed furosemide IV push
B. Place client in high Fowler's position
C. Apply oxygen via nasal cannula at 2-4 L/min
D. Encourage fluid intake of 2-3 liters per day
E. Initiate continuous cardiac monitoring
F. Administer prescribed morphine sulfate
G. Restrict sodium intake
Answer: B, C, E, F, G
Rationale: The client is experiencing acute heart failure with respiratory distress and hypoxia.
High Fowler's position (B) reduces venous return and facilitates breathing. Oxygen therapy (C)
is essential for SpO2 89%. Cardiac monitoring (E) is necessary given tachycardia and
hypotension. Morphine (F) reduces anxiety, preload, and work of breathing. Sodium restriction
(G) is part of heart failure management. Furosemide (A) should be held due to hypotension
(88/54). Encouraging fluids (D) is contraindicated in heart failure exacerbation.
,Question 2: Matrix Multiple Choice
A nurse is assessing four clients. Which client findings require immediate intervention?
Immediate Intervention
Client Finding
Needed?
78-year-old with Temperature 101.2°F, productive
Yes / No
pneumonia cough
45-year-old post- Numbness and tingling around
Yes / No
thyroidectomy mouth
Blood glucose 165 mg/dL before
62-year-old with diabetes Yes / No
lunch
25-year-old with asthma Peak flow 85% of personal best Yes / No
Answer:
78-year-old with pneumonia: No
45-year-old post-thyroidectomy: Yes
62-year-old with diabetes: No
25-year-old with asthma: No
Rationale: The post-thyroidectomy client showing numbness and tingling around the mouth
indicates hypocalcemia from possible parathyroid damage during surgery, which can progress
to tetany and laryngospasm—a life-threatening emergency requiring immediate calcium
gluconate administration. The other findings are concerning but not immediately life-
threatening.
Question 3: Bowtie/Bow-Tie Item
A 55-year-old client presents to the emergency department with chest pain.
Part 1 - Assessment Findings Most Concerning: Select the 2 findings that are most
concerning:
, A. Chest pain radiating to left arm and jaw
B. Pain rated 8/10 on pain scale
C. Diaphoresis and cool, clammy skin
D. History of hypertension
E. Last meal 2 hours ago
F. Anxiety level 7/10
Part 2 - Condition Most Likely Occurring:
Myocardial infarction
Angina pectoris
Gastroesophageal reflux disease
Panic attack
Part 3 - Priority Interventions: Select the 2 priority interventions:
A. Administer aspirin 325 mg PO
B. Obtain 12-lead ECG
C. Provide clear liquid diet
D. Administer antacid
E. Encourage deep breathing exercises
F. Prepare for immediate discharge
Answer:
Part 1: A and C
Part 2: Myocardial infarction
Part 3: A and B
Rationale: Classic MI symptoms include chest pain radiating to left arm/jaw (A) and
diaphoresis with cool, clammy skin (C) indicating sympathetic response. Priority interventions
include aspirin to prevent further platelet aggregation (A) and 12-lead ECG to confirm
diagnosis and guide treatment (B).
, Question 4: Highlight Table
Review the client's assessment data and highlight the findings that require follow-up:
A 72-year-old client with chronic kidney disease presents for follow-up.
Laboratory Results:
Potassium: 6.2 mEq/L (Normal: 3.5-5.0)
Sodium: 138 mEq/L (Normal: 136-145)
Creatinine: 3.8 mg/dL (Normal: 0.6-1.2)
BUN: 45 mg/dL (Normal: 7-20)
Hemoglobin: 9.2 g/dL (Normal: 12-16)
Calcium: 7.8 mg/dL (Normal: 9.0-10.5)
Phosphorus: 5.8 mg/dL (Normal: 3.0-4.5)
Answer: Potassium 6.2, Creatinine 3.8, BUN 45, Hemoglobin 9.2, Calcium 7.8,
Phosphorus 5.8
Rationale: Hyperkalemia (6.2) is life-threatening and requires immediate intervention to
prevent cardiac arrhythmias. Elevated creatinine and BUN indicate worsening kidney function.
Anemia is common in CKD due to decreased erythropoietin. Hypocalcemia and
hyperphosphatemia are expected complications requiring management. Sodium is within
normal limits.
Question 5: Cloze/Drop-Down
A nurse is caring for a client experiencing diabetic ketoacidosis (DKA).
The nurse anticipates the provider will prescribe [1] to be administered via [2] route. The nurse
should monitor for [3] as a potential complication of treatment.
[1] Options: insulin / glucagon / metformin / glipizide [2] Options: subcutaneous /
intramuscular / IV continuous infusion / oral [3] Options: hyperglycemia / hypoglycemia /
hyperkalemia / metabolic alkalosis
Generation Real Exam Questions
Latest Edition - Updated November 2025
SECTION 1: NEXT GENERATION ITEM TYPES -
CLINICAL JUDGMENT
Question 1: Extended Multiple Response (Select All That Apply)
A nurse is caring for a 68-year-old client admitted with heart failure exacerbation. Current vital
signs: BP 88/54 mmHg, HR 118 bpm, RR 28/min, SpO2 89% on room air, temp 98.6°F. The
client reports severe shortness of breath and anxiety. Which actions should the nurse take?
(Select all that apply)
A. Administer prescribed furosemide IV push
B. Place client in high Fowler's position
C. Apply oxygen via nasal cannula at 2-4 L/min
D. Encourage fluid intake of 2-3 liters per day
E. Initiate continuous cardiac monitoring
F. Administer prescribed morphine sulfate
G. Restrict sodium intake
Answer: B, C, E, F, G
Rationale: The client is experiencing acute heart failure with respiratory distress and hypoxia.
High Fowler's position (B) reduces venous return and facilitates breathing. Oxygen therapy (C)
is essential for SpO2 89%. Cardiac monitoring (E) is necessary given tachycardia and
hypotension. Morphine (F) reduces anxiety, preload, and work of breathing. Sodium restriction
(G) is part of heart failure management. Furosemide (A) should be held due to hypotension
(88/54). Encouraging fluids (D) is contraindicated in heart failure exacerbation.
,Question 2: Matrix Multiple Choice
A nurse is assessing four clients. Which client findings require immediate intervention?
Immediate Intervention
Client Finding
Needed?
78-year-old with Temperature 101.2°F, productive
Yes / No
pneumonia cough
45-year-old post- Numbness and tingling around
Yes / No
thyroidectomy mouth
Blood glucose 165 mg/dL before
62-year-old with diabetes Yes / No
lunch
25-year-old with asthma Peak flow 85% of personal best Yes / No
Answer:
78-year-old with pneumonia: No
45-year-old post-thyroidectomy: Yes
62-year-old with diabetes: No
25-year-old with asthma: No
Rationale: The post-thyroidectomy client showing numbness and tingling around the mouth
indicates hypocalcemia from possible parathyroid damage during surgery, which can progress
to tetany and laryngospasm—a life-threatening emergency requiring immediate calcium
gluconate administration. The other findings are concerning but not immediately life-
threatening.
Question 3: Bowtie/Bow-Tie Item
A 55-year-old client presents to the emergency department with chest pain.
Part 1 - Assessment Findings Most Concerning: Select the 2 findings that are most
concerning:
, A. Chest pain radiating to left arm and jaw
B. Pain rated 8/10 on pain scale
C. Diaphoresis and cool, clammy skin
D. History of hypertension
E. Last meal 2 hours ago
F. Anxiety level 7/10
Part 2 - Condition Most Likely Occurring:
Myocardial infarction
Angina pectoris
Gastroesophageal reflux disease
Panic attack
Part 3 - Priority Interventions: Select the 2 priority interventions:
A. Administer aspirin 325 mg PO
B. Obtain 12-lead ECG
C. Provide clear liquid diet
D. Administer antacid
E. Encourage deep breathing exercises
F. Prepare for immediate discharge
Answer:
Part 1: A and C
Part 2: Myocardial infarction
Part 3: A and B
Rationale: Classic MI symptoms include chest pain radiating to left arm/jaw (A) and
diaphoresis with cool, clammy skin (C) indicating sympathetic response. Priority interventions
include aspirin to prevent further platelet aggregation (A) and 12-lead ECG to confirm
diagnosis and guide treatment (B).
, Question 4: Highlight Table
Review the client's assessment data and highlight the findings that require follow-up:
A 72-year-old client with chronic kidney disease presents for follow-up.
Laboratory Results:
Potassium: 6.2 mEq/L (Normal: 3.5-5.0)
Sodium: 138 mEq/L (Normal: 136-145)
Creatinine: 3.8 mg/dL (Normal: 0.6-1.2)
BUN: 45 mg/dL (Normal: 7-20)
Hemoglobin: 9.2 g/dL (Normal: 12-16)
Calcium: 7.8 mg/dL (Normal: 9.0-10.5)
Phosphorus: 5.8 mg/dL (Normal: 3.0-4.5)
Answer: Potassium 6.2, Creatinine 3.8, BUN 45, Hemoglobin 9.2, Calcium 7.8,
Phosphorus 5.8
Rationale: Hyperkalemia (6.2) is life-threatening and requires immediate intervention to
prevent cardiac arrhythmias. Elevated creatinine and BUN indicate worsening kidney function.
Anemia is common in CKD due to decreased erythropoietin. Hypocalcemia and
hyperphosphatemia are expected complications requiring management. Sodium is within
normal limits.
Question 5: Cloze/Drop-Down
A nurse is caring for a client experiencing diabetic ketoacidosis (DKA).
The nurse anticipates the provider will prescribe [1] to be administered via [2] route. The nurse
should monitor for [3] as a potential complication of treatment.
[1] Options: insulin / glucagon / metformin / glipizide [2] Options: subcutaneous /
intramuscular / IV continuous infusion / oral [3] Options: hyperglycemia / hypoglycemia /
hyperkalemia / metabolic alkalosis
