NCLEX-RN COMPREHENSIVE PRACTICE
EXAM 2026
Pharmacology & Medication Administration
Total Questions: 50 | Time Recommended: 75 minutes Passing Standard:
Aligned with 2025–2026 NCLEX-RN Test Plan
SECTION 1: CARDIOVASCULAR
MEDICATIONS
Question 1
A 68-year-old male with a history of heart failure (NYHA Class III) is admitted with
worsening dyspnea and 3+ pitting edema of the lower extremities. Current medications
include lisinopril 20 mg PO daily, carvedilol 25 mg PO BID, and furosemide 40 mg PO daily.
Vital signs: BP 98/62 mmHg, HR 52 bpm, RR 24 breaths/min, SpO2 91% on room air. The
morning lab results show serum potassium 5.8 mEq/L and serum creatinine 2.4 mg/dL.
Which medication should the nurse anticipate the provider will hold or discontinue first?
A) Carvedilol B) Lisinopril C) Furosemide D) All three medications should be discontinued
simultaneously
Correct answer: B
Explanation:
Lisinopril, an ACE inhibitor, should be held first because it directly contributes to
hyperkalemia by reducing aldosterone secretion and decreasing renal potassium
excretion. Combined with worsening renal function (creatinine 2.4 mg/dL) and a
dangerously elevated potassium of 5.8 mEq/L, continuing this medication poses an
immediate risk of fatal cardiac arrhythmia.
(A) Carvedilol contributes to bradycardia (HR 52) and hypotension (BP 98/62), and
may also warrant reassessment, but it does not directly worsen the most
immediately life-threatening finding — the hyperkalemia.
(C) Furosemide is a loop diuretic that actually promotes potassium excretion;
discontinuing it would worsen the hyperkalemia and the fluid overload. It should be
, continued or increased.
(D) Discontinuing all three simultaneously is not evidence-based. Furosemide is
beneficial in this scenario, and abrupt withdrawal of all heart failure medications
would destabilize the patient.
NCLEX Category: Physiological Integrity — Pharmacological and Parenteral
Therapies
Cognitive Level: Analysis
Question 2
A 72-year-old female with chronic atrial fibrillation is taking warfarin 5 mg PO daily. She
presents to the clinic for routine INR monitoring. Her INR is 4.8 (therapeutic range 2.0–
3.0). She denies any bleeding but reports she started taking an herbal supplement
containing St. John's wort one week ago, then stopped it two days ago. Vital signs: BP
138/82 mmHg, HR 78 bpm (irregularly irregular), RR 16 breaths/min, SpO2 97% on room
air.
What is the most likely explanation for the elevated INR?
A) St. John's wort directly potentiates warfarin's anticoagulant effect B) Discontinuation of
St. John's wort removed a CYP450 enzyme inducer, causing warfarin levels to rise C) The
patient likely consumed excess vitamin K–rich foods D) Atrial fibrillation exacerbation is
increasing clot breakdown and falsely elevating the INR
Correct answer: B
Explanation:
St. John's wort is a potent inducer of CYP3A4 and CYP2C9 enzymes. While taking it,
warfarin metabolism is accelerated, reducing its effect. When the patient stopped St.
John's wort two days ago, the enzyme induction began to wane, and warfarin levels
accumulated because the dose had been calibrated to the induced state. This
"rebound" effect is a classic and dangerous drug-herb interaction.
(A) St. John's wort actually reduces warfarin levels by inducing its metabolism — it
does not potentiate warfarin. This answer reflects a common misconception.
(C) Excess vitamin K–rich foods would decrease the INR (vitamin K antagonizes
warfarin), not increase it.
(D) Atrial fibrillation does not cause clot breakdown that would affect INR
measurement. INR measures the extrinsic coagulation pathway, not fibrinolysis.
NCLEX Category: Physiological Integrity — Pharmacological and Parenteral
Therapies
Cognitive Level: Analysis
Question 3
,A 58-year-old male is 12 hours post-percutaneous coronary intervention (PCI) with drug-
eluting stent placement to the left anterior descending artery. He is on dual antiplatelet
therapy: aspirin 81 mg PO daily and clopidogrel (Plavix) 75 mg PO daily. He reports new-
onset severe epigastric pain. Vital signs: BP 110/70 mmHg, HR 104 bpm, RR 20
breaths/min, SpO2 96% on room air. Stool guaiac is positive. Hemoglobin is 9.2 g/dL (pre-
procedure 13.8 g/dL).
Which action should the nurse prioritize?
A) Hold both aspirin and clopidogrel and notify the provider immediately B) Administer
omeprazole 40 mg IV and notify the provider C) Notify the provider immediately; do not
independently discontinue antiplatelet therapy D) Administer vitamin K 10 mg IV to
reverse the anticoagulation
Correct answer: C
Explanation:
The nurse must notify the provider immediately because this patient is experiencing
a significant GI bleed (positive guaiac, hemoglobin drop of 4.6 g/dL, tachycardia).
However, the nurse should NOT independently discontinue dual antiplatelet therapy
— premature cessation within the first 24–48 hours post-drug-eluting stent
placement carries a catastrophic risk of acute stent thrombosis, which has a
mortality rate of 20–40%. This decision must be made by the provider who can
weigh the competing risks.
(A) Independently holding both antiplatelet agents is outside the nurse's scope in
this context and could precipitate fatal stent thrombosis. The provider must make
this risk-benefit decision.
(B) While a proton pump inhibitor may be appropriate, administering it without a
provider order and without first notifying the provider of the acute bleed does not
address the urgency of the clinical picture.
(D) Vitamin K reverses warfarin, not antiplatelet agents. Aspirin and clopidogrel are
not anticoagulants — they inhibit platelet aggregation through irreversible COX-1
and ADP-receptor blockade, respectively.
NCLEX Category: Physiological Integrity — Pharmacological and Parenteral
Therapies
Cognitive Level: Analysis
Question 4
A nurse is preparing to administer digoxin 0.125 mg PO daily to a 78-year-old female with
heart failure and atrial fibrillation. The patient's morning assessment reveals: BP 132/78
mmHg, apical HR 56 bpm, RR 18 breaths/min, SpO2 95% on 2L nasal cannula. Lab results:
serum digoxin level 2.4 ng/mL (therapeutic range 0.8–2.0 ng/mL), potassium 3.2 mEq/L,
creatinine 1.8 mg/dL.
, Which combination of findings is MOST concerning for digoxin toxicity? (Select all that
apply.)
A) Apical heart rate of 56 bpm B) Serum digoxin level of 2.4 ng/mL C) Serum potassium of
3.2 mEq/L D) Serum creatinine of 1.8 mg/dL E) Blood pressure of 132/78 mmHg F) SpO2
of 95% on 2L nasal cannula
Correct answer: A, B, C, D
Explanation:
(A) CORRECT — Bradycardia (HR <60 bpm) is a hallmark sign of digoxin toxicity. The
nurse should hold digoxin when the apical pulse is below 60 bpm in adults.
(B) CORRECT — A digoxin level of 2.4 ng/mL exceeds the therapeutic range (0.8–2.0
ng/mL), confirming supratherapeutic levels and toxicity risk.
(C) CORRECT — Hypokalemia (K+ 3.2 mEq/L; normal 3.5–5.0 mEq/L) dramatically
increases the risk of digoxin toxicity because digoxin and potassium compete for the
same binding site on the Na+/K+-ATPase pump. Low potassium means more digoxin
binds, amplifying its toxic effects.
(D) CORRECT — Elevated creatinine (1.8 mg/dL) indicates impaired renal function.
Digoxin is primarily excreted renally; decreased clearance causes drug accumulation
and toxicity.
(E) INCORRECT — BP of 132/78 mmHg is within normal limits and does not directly
indicate digoxin toxicity.
(F) INCORRECT — SpO2 of 95% on supplemental oxygen is acceptable for a heart
failure patient and is not a direct indicator of digoxin toxicity.
NCLEX Category: Physiological Integrity — Pharmacological and Parenteral
Therapies
Cognitive Level: Analysis
Question 5
A 55-year-old male with newly diagnosed essential hypertension (BP consistently 158/96
mmHg) and a history of type 2 diabetes mellitus with microalbuminuria is being started
on antihypertensive therapy. Serum creatinine is 1.1 mg/dL, potassium 4.2 mEq/L, and
HbA1c 7.8%. He has no history of angioedema.
Which antihypertensive class is the BEST first-line choice for this patient?
A) Calcium channel blocker (amlodipine) B) ACE inhibitor (lisinopril) C) Thiazide diuretic
(hydrochlorothiazide) D) Beta-blocker (metoprolol)
Correct answer: B
Explanation:
EXAM 2026
Pharmacology & Medication Administration
Total Questions: 50 | Time Recommended: 75 minutes Passing Standard:
Aligned with 2025–2026 NCLEX-RN Test Plan
SECTION 1: CARDIOVASCULAR
MEDICATIONS
Question 1
A 68-year-old male with a history of heart failure (NYHA Class III) is admitted with
worsening dyspnea and 3+ pitting edema of the lower extremities. Current medications
include lisinopril 20 mg PO daily, carvedilol 25 mg PO BID, and furosemide 40 mg PO daily.
Vital signs: BP 98/62 mmHg, HR 52 bpm, RR 24 breaths/min, SpO2 91% on room air. The
morning lab results show serum potassium 5.8 mEq/L and serum creatinine 2.4 mg/dL.
Which medication should the nurse anticipate the provider will hold or discontinue first?
A) Carvedilol B) Lisinopril C) Furosemide D) All three medications should be discontinued
simultaneously
Correct answer: B
Explanation:
Lisinopril, an ACE inhibitor, should be held first because it directly contributes to
hyperkalemia by reducing aldosterone secretion and decreasing renal potassium
excretion. Combined with worsening renal function (creatinine 2.4 mg/dL) and a
dangerously elevated potassium of 5.8 mEq/L, continuing this medication poses an
immediate risk of fatal cardiac arrhythmia.
(A) Carvedilol contributes to bradycardia (HR 52) and hypotension (BP 98/62), and
may also warrant reassessment, but it does not directly worsen the most
immediately life-threatening finding — the hyperkalemia.
(C) Furosemide is a loop diuretic that actually promotes potassium excretion;
discontinuing it would worsen the hyperkalemia and the fluid overload. It should be
, continued or increased.
(D) Discontinuing all three simultaneously is not evidence-based. Furosemide is
beneficial in this scenario, and abrupt withdrawal of all heart failure medications
would destabilize the patient.
NCLEX Category: Physiological Integrity — Pharmacological and Parenteral
Therapies
Cognitive Level: Analysis
Question 2
A 72-year-old female with chronic atrial fibrillation is taking warfarin 5 mg PO daily. She
presents to the clinic for routine INR monitoring. Her INR is 4.8 (therapeutic range 2.0–
3.0). She denies any bleeding but reports she started taking an herbal supplement
containing St. John's wort one week ago, then stopped it two days ago. Vital signs: BP
138/82 mmHg, HR 78 bpm (irregularly irregular), RR 16 breaths/min, SpO2 97% on room
air.
What is the most likely explanation for the elevated INR?
A) St. John's wort directly potentiates warfarin's anticoagulant effect B) Discontinuation of
St. John's wort removed a CYP450 enzyme inducer, causing warfarin levels to rise C) The
patient likely consumed excess vitamin K–rich foods D) Atrial fibrillation exacerbation is
increasing clot breakdown and falsely elevating the INR
Correct answer: B
Explanation:
St. John's wort is a potent inducer of CYP3A4 and CYP2C9 enzymes. While taking it,
warfarin metabolism is accelerated, reducing its effect. When the patient stopped St.
John's wort two days ago, the enzyme induction began to wane, and warfarin levels
accumulated because the dose had been calibrated to the induced state. This
"rebound" effect is a classic and dangerous drug-herb interaction.
(A) St. John's wort actually reduces warfarin levels by inducing its metabolism — it
does not potentiate warfarin. This answer reflects a common misconception.
(C) Excess vitamin K–rich foods would decrease the INR (vitamin K antagonizes
warfarin), not increase it.
(D) Atrial fibrillation does not cause clot breakdown that would affect INR
measurement. INR measures the extrinsic coagulation pathway, not fibrinolysis.
NCLEX Category: Physiological Integrity — Pharmacological and Parenteral
Therapies
Cognitive Level: Analysis
Question 3
,A 58-year-old male is 12 hours post-percutaneous coronary intervention (PCI) with drug-
eluting stent placement to the left anterior descending artery. He is on dual antiplatelet
therapy: aspirin 81 mg PO daily and clopidogrel (Plavix) 75 mg PO daily. He reports new-
onset severe epigastric pain. Vital signs: BP 110/70 mmHg, HR 104 bpm, RR 20
breaths/min, SpO2 96% on room air. Stool guaiac is positive. Hemoglobin is 9.2 g/dL (pre-
procedure 13.8 g/dL).
Which action should the nurse prioritize?
A) Hold both aspirin and clopidogrel and notify the provider immediately B) Administer
omeprazole 40 mg IV and notify the provider C) Notify the provider immediately; do not
independently discontinue antiplatelet therapy D) Administer vitamin K 10 mg IV to
reverse the anticoagulation
Correct answer: C
Explanation:
The nurse must notify the provider immediately because this patient is experiencing
a significant GI bleed (positive guaiac, hemoglobin drop of 4.6 g/dL, tachycardia).
However, the nurse should NOT independently discontinue dual antiplatelet therapy
— premature cessation within the first 24–48 hours post-drug-eluting stent
placement carries a catastrophic risk of acute stent thrombosis, which has a
mortality rate of 20–40%. This decision must be made by the provider who can
weigh the competing risks.
(A) Independently holding both antiplatelet agents is outside the nurse's scope in
this context and could precipitate fatal stent thrombosis. The provider must make
this risk-benefit decision.
(B) While a proton pump inhibitor may be appropriate, administering it without a
provider order and without first notifying the provider of the acute bleed does not
address the urgency of the clinical picture.
(D) Vitamin K reverses warfarin, not antiplatelet agents. Aspirin and clopidogrel are
not anticoagulants — they inhibit platelet aggregation through irreversible COX-1
and ADP-receptor blockade, respectively.
NCLEX Category: Physiological Integrity — Pharmacological and Parenteral
Therapies
Cognitive Level: Analysis
Question 4
A nurse is preparing to administer digoxin 0.125 mg PO daily to a 78-year-old female with
heart failure and atrial fibrillation. The patient's morning assessment reveals: BP 132/78
mmHg, apical HR 56 bpm, RR 18 breaths/min, SpO2 95% on 2L nasal cannula. Lab results:
serum digoxin level 2.4 ng/mL (therapeutic range 0.8–2.0 ng/mL), potassium 3.2 mEq/L,
creatinine 1.8 mg/dL.
, Which combination of findings is MOST concerning for digoxin toxicity? (Select all that
apply.)
A) Apical heart rate of 56 bpm B) Serum digoxin level of 2.4 ng/mL C) Serum potassium of
3.2 mEq/L D) Serum creatinine of 1.8 mg/dL E) Blood pressure of 132/78 mmHg F) SpO2
of 95% on 2L nasal cannula
Correct answer: A, B, C, D
Explanation:
(A) CORRECT — Bradycardia (HR <60 bpm) is a hallmark sign of digoxin toxicity. The
nurse should hold digoxin when the apical pulse is below 60 bpm in adults.
(B) CORRECT — A digoxin level of 2.4 ng/mL exceeds the therapeutic range (0.8–2.0
ng/mL), confirming supratherapeutic levels and toxicity risk.
(C) CORRECT — Hypokalemia (K+ 3.2 mEq/L; normal 3.5–5.0 mEq/L) dramatically
increases the risk of digoxin toxicity because digoxin and potassium compete for the
same binding site on the Na+/K+-ATPase pump. Low potassium means more digoxin
binds, amplifying its toxic effects.
(D) CORRECT — Elevated creatinine (1.8 mg/dL) indicates impaired renal function.
Digoxin is primarily excreted renally; decreased clearance causes drug accumulation
and toxicity.
(E) INCORRECT — BP of 132/78 mmHg is within normal limits and does not directly
indicate digoxin toxicity.
(F) INCORRECT — SpO2 of 95% on supplemental oxygen is acceptable for a heart
failure patient and is not a direct indicator of digoxin toxicity.
NCLEX Category: Physiological Integrity — Pharmacological and Parenteral
Therapies
Cognitive Level: Analysis
Question 5
A 55-year-old male with newly diagnosed essential hypertension (BP consistently 158/96
mmHg) and a history of type 2 diabetes mellitus with microalbuminuria is being started
on antihypertensive therapy. Serum creatinine is 1.1 mg/dL, potassium 4.2 mEq/L, and
HbA1c 7.8%. He has no history of angioedema.
Which antihypertensive class is the BEST first-line choice for this patient?
A) Calcium channel blocker (amlodipine) B) ACE inhibitor (lisinopril) C) Thiazide diuretic
(hydrochlorothiazide) D) Beta-blocker (metoprolol)
Correct answer: B
Explanation:
