NCLEX NGN RN (WITH ALL QUESTIONS
FORMART) NEWEST ACTUAL EXAM ALL AND
CORRECT DETAILED ANSWERS WITH
RATIONALES|ALREADY GRADED A+
1. A nurse is caring for a patient with acute pancreatitis who has a nasogastric tube to low
intermittent suction. The patient reports severe abdominal pain rated 8/10. The nurse reviews the
electronic health record and notes the patient has a history of chronic alcohol use and is currently
on a continuous infusion of heparin for a deep vein thrombosis. Which of the following actions
should the nurse take first?
A. Administer IV morphine 4 mg as prescribed.
B. Check the nasogastric tube for patency and placement.
C. Hold the heparin infusion and notify the provider.
D. Reposition the patient onto the left side.
Answer: B
Rationale: In acute pancreatitis, severe pain can indicate worsening inflammation or complications.
Assessing NG tube patency and placement is essential to ensure decompression is effective; obstruction
or malposition can exacerbate pain. Pain medication (A) may be given after assessment. Holding
heparin (C) is not indicated without signs of bleeding. Repositioning (D) is a comfort measure but does
not address the underlying cause of pain.
2. A nurse is reviewing the laboratory results of a patient with chronic kidney disease stage 4.
Which of the following findings is most indicative of a need to adjust the patient's calcium and
vitamin D supplementation?
A. Serum calcium 9.2 mg/dL, phosphate 4.0 mg/dL, PTH 120 pg/mL
B. Serum calcium 8.6 mg/dL, phosphate 6.5 mg/dL, PTH 250 pg/mL
C. Serum calcium 10.1 mg/dL, phosphate 3.8 mg/dL, PTH 45 pg/mL
D. Serum calcium 9.0 mg/dL, phosphate 5.0 mg/dL, PTH 90 pg/mL
Answer: B
Rationale: In CKD, hyperphosphatemia and hypocalcemia stimulate PTH secretion (secondary
hyperparathyroidism). Option B shows hypocalcemia (8.6 mg/dL), hyperphosphatemia (6.5 mg/dL), and
markedly elevated PTH (250 pg/mL), indicating the need for phosphate binders and active vitamin D
(calcitriol) to suppress PTH. Options A, C, and D have less deranged values and do not require
immediate adjustment.
Page 1
,3. A nurse is caring for a patient with a new diagnosis of type 2 diabetes mellitus. The patient is
started on metformin 500 mg twice daily. Which of the following statements by the patient
indicates an accurate understanding of the medication?
A. I should take this medication with meals to prevent an upset stomach.
B. I need to avoid eating foods that contain vitamin K while on this medication.
C. If I miss a dose, I can double the next dose to make up for it.
D. This medication will help my pancreas produce more insulin.
Answer: A
Rationale: Metformin is best taken with meals to reduce gastrointestinal side effects. Option B refers to
warfarin, not metformin. Option C is dangerous; missed doses should not be doubled. Option D is
incorrect; metformin primarily decreases hepatic glucose production and improves insulin sensitivity,
not insulin secretion.
4. A nurse is assessing a patient who is receiving a continuous infusion of 0.9% sodium chloride at
150 mL/hr. The patient has a history of heart failure and chronic kidney disease. Which of the
following findings should the nurse report to the provider immediately?
A. Serum sodium 140 mEq/L
B. Urine output 20 mL over the past 2 hours
C. Blood pressure 110/70 mmHg
D. Heart rate 80 beats per minute
Answer: B
Rationale: A urine output of 20 mL over 2 hours (10 mL/hr) indicates oliguria, which in the context of
heart failure and CKD suggests fluid overload or worsening renal function. The high IV rate (150
mL/hr) may be contributing to fluid overload. Option A is normal. Options C and D are within normal
limits and do not require immediate reporting.
5. A nurse is preparing to administer a blood transfusion to a patient with anemia. The patient has
a history of multiple transfusions and is at risk for a transfusion reaction. Which of the following
actions is most important for the nurse to take to prevent a febrile non-hemolytic transfusion
reaction?
A. Premedicate with acetaminophen and diphenhydramine as prescribed.
B. Use a leukocyte-reduced blood product.
C. Ensure the blood is infused within 4 hours of removal from the blood bank.
D. Obtain vital signs every 15 minutes during the transfusion.
Answer: B
Rationale: Febrile non-hemolytic transfusion reactions are commonly caused by antibodies against donor
leukocytes. Leukocyte-reduced blood products significantly reduce the risk of this reaction.
Premedication (A) may help but is not the most important preventive measure. Options C and D are
standard practices but do not prevent the reaction.
Page 2
,6. A nurse is caring for a patient with a chest tube connected to a dry suction water seal drainage
system. The patient is being transported to the radiology department. Which of the following
actions should the nurse take to ensure safe transport?
A. Clamp the chest tube for the duration of the transport.
B. Keep the drainage system below the level of the chest and maintain suction.
C. Disconnect the chest tube from the drainage system and cap it.
D. Place the drainage system on the patient's bed and keep suction off.
Answer: B
Rationale: The drainage system must remain below chest level to prevent backflow of fluid into the
pleural space. Suction should be maintained to ensure continuous drainage. Clamping (A) can cause
tension pneumothorax if there is an air leak. Disconnecting (C) breaks the sterile system and risks
infection. Placing on the bed (D) may cause the system to rise above the chest.
7. A nurse is evaluating a patient's readiness for discharge after a total hip arthroplasty. Which of
the following findings indicates that the patient requires further teaching?
A. The patient uses a raised toilet seat.
B. The patient sits in a low, soft armchair.
C. The patient places a pillow between the legs when lying on the non-operative side.
D. The patient uses a long-handled shoe horn to put on shoes.
Answer: B
Rationale: After total hip arthroplasty, patients must avoid hip flexion beyond 90 degrees and adduction.
Sitting in a low, soft armchair can cause excessive hip flexion and dislocation risk. Options A, C, and D
are appropriate: raised toilet seat reduces flexion, pillow between legs prevents adduction, long-handled
shoe horn avoids bending.
8. A nurse is caring for a patient with a pulmonary embolism who is receiving a continuous
infusion of unfractionated heparin. The aPTT is 90 seconds (therapeutic range 60-80 seconds).
Which of the following actions should the nurse take?
A. Decrease the heparin infusion rate by 2 units/kg/hr.
B. Increase the heparin infusion rate by 2 units/kg/hr.
C. Administer protamine sulfate 1 mg IV.
D. Continue the current infusion rate and recheck aPTT in 6 hours.
Answer: A
Rationale: An aPTT of 90 seconds is above the therapeutic range (60-80 seconds), indicating an
increased bleeding risk. The nurse should decrease the infusion rate per protocol. Increasing (B) would
worsen the situation. Protamine (C) is for severe bleeding or reversal, not for slight elevation.
Continuing (D) would not address the supratherapeutic level.
9. A nurse is delegating tasks to an unlicensed assistive personnel (UAP) on a medical-surgical unit.
Which of the following tasks should the nurse delegate to the UAP?
A. Assisting a patient with a new colostomy to change the appliance.
B. Feeding a patient with dysphagia who requires a pureed diet.
Page 3
, C. Obtaining a routine urine specimen from a patient with an indwelling catheter.
D. Ambulating a patient who is 1 day post-operative from a hip replacement.
Answer: C
Rationale: Obtaining a routine urine specimen from an indwelling catheter is a non-invasive, stable task
that UAPs can perform. Option A involves teaching and complex care (colostomy) that requires a
licensed nurse. Option B involves a patient with dysphagia, which carries a risk of aspiration and
requires nursing judgment. Option D is a post-operative patient who needs assessment for stability
before ambulation.
10. A nurse is providing discharge teaching to a patient who has a new prescription for warfarin.
Which of the following statements by the patient indicates a need for further teaching?
A. I will use an electric razor for shaving.
B. I will avoid eating large amounts of green leafy vegetables.
C. I will take aspirin if I get a headache.
D. I will notify my dentist about this medication before any dental work.
Answer: C
Rationale: Aspirin increases the risk of bleeding when combined with warfarin and should be avoided
unless specifically prescribed. Option A is correct to prevent cuts. Option B is correct because vitamin K
in green leafy vegetables can affect INR. Option D is correct to manage bleeding risk during dental
procedures.
11. A patient with a history of chronic kidney disease (CKD) stage 4 is admitted with hyperkalemia
(K+ 6.2 mEq/L) and ECG changes showing peaked T waves. The nurse administers intravenous
calcium gluconate. Which mechanism best explains the immediate therapeutic effect of this
intervention?
A. Calcium shifts potassium intracellularly by activating the Na+/K+ ATPase pump.
B. Calcium directly binds to and neutralizes serum potassium ions.
C. Calcium increases renal excretion of potassium through the distal tubule.
D. Calcium stabilizes the cardiac cell membrane by raising the threshold potential.
Answer: D
Rationale: Calcium gluconate does not lower serum potassium but stabilizes myocardial membranes,
reducing the risk of ventricular fibrillation. It raises the threshold potential, making the cell less
excitable. Options A and B describe mechanisms of insulin/dextrose and sodium bicarbonate, while C is
unrelated to calcium action.
12. A patient receiving a continuous infusion of heparin for treatment of pulmonary embolism
develops a sudden onset of severe lower back pain, hypotension, and a decrease in hemoglobin
from 13.5 g/dL to 8.2 g/dL over 6 hours. Which complication should the nurse suspect?
A. Heparin-induced thrombocytopenia (HIT) with arterial thrombosis
B. Retroperitoneal hemorrhage due to heparin therapy
C. Pulmonary embolism progression causing hemorrhagic infarction
D. Disseminated intravascular coagulation (DIC) secondary to heparin
Page 4
FORMART) NEWEST ACTUAL EXAM ALL AND
CORRECT DETAILED ANSWERS WITH
RATIONALES|ALREADY GRADED A+
1. A nurse is caring for a patient with acute pancreatitis who has a nasogastric tube to low
intermittent suction. The patient reports severe abdominal pain rated 8/10. The nurse reviews the
electronic health record and notes the patient has a history of chronic alcohol use and is currently
on a continuous infusion of heparin for a deep vein thrombosis. Which of the following actions
should the nurse take first?
A. Administer IV morphine 4 mg as prescribed.
B. Check the nasogastric tube for patency and placement.
C. Hold the heparin infusion and notify the provider.
D. Reposition the patient onto the left side.
Answer: B
Rationale: In acute pancreatitis, severe pain can indicate worsening inflammation or complications.
Assessing NG tube patency and placement is essential to ensure decompression is effective; obstruction
or malposition can exacerbate pain. Pain medication (A) may be given after assessment. Holding
heparin (C) is not indicated without signs of bleeding. Repositioning (D) is a comfort measure but does
not address the underlying cause of pain.
2. A nurse is reviewing the laboratory results of a patient with chronic kidney disease stage 4.
Which of the following findings is most indicative of a need to adjust the patient's calcium and
vitamin D supplementation?
A. Serum calcium 9.2 mg/dL, phosphate 4.0 mg/dL, PTH 120 pg/mL
B. Serum calcium 8.6 mg/dL, phosphate 6.5 mg/dL, PTH 250 pg/mL
C. Serum calcium 10.1 mg/dL, phosphate 3.8 mg/dL, PTH 45 pg/mL
D. Serum calcium 9.0 mg/dL, phosphate 5.0 mg/dL, PTH 90 pg/mL
Answer: B
Rationale: In CKD, hyperphosphatemia and hypocalcemia stimulate PTH secretion (secondary
hyperparathyroidism). Option B shows hypocalcemia (8.6 mg/dL), hyperphosphatemia (6.5 mg/dL), and
markedly elevated PTH (250 pg/mL), indicating the need for phosphate binders and active vitamin D
(calcitriol) to suppress PTH. Options A, C, and D have less deranged values and do not require
immediate adjustment.
Page 1
,3. A nurse is caring for a patient with a new diagnosis of type 2 diabetes mellitus. The patient is
started on metformin 500 mg twice daily. Which of the following statements by the patient
indicates an accurate understanding of the medication?
A. I should take this medication with meals to prevent an upset stomach.
B. I need to avoid eating foods that contain vitamin K while on this medication.
C. If I miss a dose, I can double the next dose to make up for it.
D. This medication will help my pancreas produce more insulin.
Answer: A
Rationale: Metformin is best taken with meals to reduce gastrointestinal side effects. Option B refers to
warfarin, not metformin. Option C is dangerous; missed doses should not be doubled. Option D is
incorrect; metformin primarily decreases hepatic glucose production and improves insulin sensitivity,
not insulin secretion.
4. A nurse is assessing a patient who is receiving a continuous infusion of 0.9% sodium chloride at
150 mL/hr. The patient has a history of heart failure and chronic kidney disease. Which of the
following findings should the nurse report to the provider immediately?
A. Serum sodium 140 mEq/L
B. Urine output 20 mL over the past 2 hours
C. Blood pressure 110/70 mmHg
D. Heart rate 80 beats per minute
Answer: B
Rationale: A urine output of 20 mL over 2 hours (10 mL/hr) indicates oliguria, which in the context of
heart failure and CKD suggests fluid overload or worsening renal function. The high IV rate (150
mL/hr) may be contributing to fluid overload. Option A is normal. Options C and D are within normal
limits and do not require immediate reporting.
5. A nurse is preparing to administer a blood transfusion to a patient with anemia. The patient has
a history of multiple transfusions and is at risk for a transfusion reaction. Which of the following
actions is most important for the nurse to take to prevent a febrile non-hemolytic transfusion
reaction?
A. Premedicate with acetaminophen and diphenhydramine as prescribed.
B. Use a leukocyte-reduced blood product.
C. Ensure the blood is infused within 4 hours of removal from the blood bank.
D. Obtain vital signs every 15 minutes during the transfusion.
Answer: B
Rationale: Febrile non-hemolytic transfusion reactions are commonly caused by antibodies against donor
leukocytes. Leukocyte-reduced blood products significantly reduce the risk of this reaction.
Premedication (A) may help but is not the most important preventive measure. Options C and D are
standard practices but do not prevent the reaction.
Page 2
,6. A nurse is caring for a patient with a chest tube connected to a dry suction water seal drainage
system. The patient is being transported to the radiology department. Which of the following
actions should the nurse take to ensure safe transport?
A. Clamp the chest tube for the duration of the transport.
B. Keep the drainage system below the level of the chest and maintain suction.
C. Disconnect the chest tube from the drainage system and cap it.
D. Place the drainage system on the patient's bed and keep suction off.
Answer: B
Rationale: The drainage system must remain below chest level to prevent backflow of fluid into the
pleural space. Suction should be maintained to ensure continuous drainage. Clamping (A) can cause
tension pneumothorax if there is an air leak. Disconnecting (C) breaks the sterile system and risks
infection. Placing on the bed (D) may cause the system to rise above the chest.
7. A nurse is evaluating a patient's readiness for discharge after a total hip arthroplasty. Which of
the following findings indicates that the patient requires further teaching?
A. The patient uses a raised toilet seat.
B. The patient sits in a low, soft armchair.
C. The patient places a pillow between the legs when lying on the non-operative side.
D. The patient uses a long-handled shoe horn to put on shoes.
Answer: B
Rationale: After total hip arthroplasty, patients must avoid hip flexion beyond 90 degrees and adduction.
Sitting in a low, soft armchair can cause excessive hip flexion and dislocation risk. Options A, C, and D
are appropriate: raised toilet seat reduces flexion, pillow between legs prevents adduction, long-handled
shoe horn avoids bending.
8. A nurse is caring for a patient with a pulmonary embolism who is receiving a continuous
infusion of unfractionated heparin. The aPTT is 90 seconds (therapeutic range 60-80 seconds).
Which of the following actions should the nurse take?
A. Decrease the heparin infusion rate by 2 units/kg/hr.
B. Increase the heparin infusion rate by 2 units/kg/hr.
C. Administer protamine sulfate 1 mg IV.
D. Continue the current infusion rate and recheck aPTT in 6 hours.
Answer: A
Rationale: An aPTT of 90 seconds is above the therapeutic range (60-80 seconds), indicating an
increased bleeding risk. The nurse should decrease the infusion rate per protocol. Increasing (B) would
worsen the situation. Protamine (C) is for severe bleeding or reversal, not for slight elevation.
Continuing (D) would not address the supratherapeutic level.
9. A nurse is delegating tasks to an unlicensed assistive personnel (UAP) on a medical-surgical unit.
Which of the following tasks should the nurse delegate to the UAP?
A. Assisting a patient with a new colostomy to change the appliance.
B. Feeding a patient with dysphagia who requires a pureed diet.
Page 3
, C. Obtaining a routine urine specimen from a patient with an indwelling catheter.
D. Ambulating a patient who is 1 day post-operative from a hip replacement.
Answer: C
Rationale: Obtaining a routine urine specimen from an indwelling catheter is a non-invasive, stable task
that UAPs can perform. Option A involves teaching and complex care (colostomy) that requires a
licensed nurse. Option B involves a patient with dysphagia, which carries a risk of aspiration and
requires nursing judgment. Option D is a post-operative patient who needs assessment for stability
before ambulation.
10. A nurse is providing discharge teaching to a patient who has a new prescription for warfarin.
Which of the following statements by the patient indicates a need for further teaching?
A. I will use an electric razor for shaving.
B. I will avoid eating large amounts of green leafy vegetables.
C. I will take aspirin if I get a headache.
D. I will notify my dentist about this medication before any dental work.
Answer: C
Rationale: Aspirin increases the risk of bleeding when combined with warfarin and should be avoided
unless specifically prescribed. Option A is correct to prevent cuts. Option B is correct because vitamin K
in green leafy vegetables can affect INR. Option D is correct to manage bleeding risk during dental
procedures.
11. A patient with a history of chronic kidney disease (CKD) stage 4 is admitted with hyperkalemia
(K+ 6.2 mEq/L) and ECG changes showing peaked T waves. The nurse administers intravenous
calcium gluconate. Which mechanism best explains the immediate therapeutic effect of this
intervention?
A. Calcium shifts potassium intracellularly by activating the Na+/K+ ATPase pump.
B. Calcium directly binds to and neutralizes serum potassium ions.
C. Calcium increases renal excretion of potassium through the distal tubule.
D. Calcium stabilizes the cardiac cell membrane by raising the threshold potential.
Answer: D
Rationale: Calcium gluconate does not lower serum potassium but stabilizes myocardial membranes,
reducing the risk of ventricular fibrillation. It raises the threshold potential, making the cell less
excitable. Options A and B describe mechanisms of insulin/dextrose and sodium bicarbonate, while C is
unrelated to calcium action.
12. A patient receiving a continuous infusion of heparin for treatment of pulmonary embolism
develops a sudden onset of severe lower back pain, hypotension, and a decrease in hemoglobin
from 13.5 g/dL to 8.2 g/dL over 6 hours. Which complication should the nurse suspect?
A. Heparin-induced thrombocytopenia (HIT) with arterial thrombosis
B. Retroperitoneal hemorrhage due to heparin therapy
C. Pulmonary embolism progression causing hemorrhagic infarction
D. Disseminated intravascular coagulation (DIC) secondary to heparin
Page 4
