Free NCLEX RN Practice Questions & NGN Question Bank

Correct answer: B

1. Offer oral water. Aspiration risk and delayed care.
2. Assess airway and activate urgent assistance. Correct: stridor suggests critical airway obstruction.
3. Give discharge instructions. Education is not priority.
4. Wait for routine assessment. Urgent escalation is needed.

Correct answer: C

1. Document an expected effect. Melena is a bleeding warning sign.
2. Give the next dose. Additional anticoagulant may worsen suspected bleeding.
3. Assess bleeding and vital signs; promptly notify the prescriber. Correct: assess possible hemorrhage and escalate.
4. Encourage exercise. Exercise is not treatment.

Correct answer: A, B, D, F

1. Begin ECG monitoring. Correct: watch for life-threatening dysrhythmia.
2. Escalate immediately. Correct: urgent medical response.
3. Administer potassium supplement. Potassium could worsen hyperkalemia.
4. Prepare ordered emergency treatments. Correct: prepare prescribed therapy.
5. Wait until next shift. Unsafe delay.
6. Review potassium-raising medications. Correct: identify contributing medicines.

Correct answer: B, D, E, F

1. Encourage symptomatic visitors. Symptomatic visitors increase risk.
2. Perform hand hygiene. Correct: reduces transmission.
3. Ignore mouth ulcers. Mucositis needs assessment.
4. Assess for infection with subtle inflammatory findings. Correct: infection signs can be subtle.
5. Assess fever urgently. Correct: neutropenic fever can be an emergency.
6. Follow appropriate infection and food-safety precautions. Correct: infection prevention is essential.

Correct answer: A, B, D

1. New facial droop. Correct: new facial asymmetry.
2. New unilateral arm weakness. Correct: one-sided weakness.
3. Stable arthritis. Unchanged arthritis is unrelated.
4. Sudden speech difficulty. Correct: aphasia or dysarthria.
5. Old ankle scar. Old scar is not a new neurologic cue.

Correct answer: A, B

1. Respirations 8/min. Correct: respiratory depression.
2. Absent deep tendon reflexes. Correct: absent reflexes suggest toxicity.
3. Warm sensation after infusion. Warmth alone is not the leading toxicity cue.
4. Urine output improving. Adequate urine output is reassuring.
5. Headache resolving. Improvement alone is not toxicity.

Assume a stable client and local policy permitting ordinary UAP tasks.

Initial assessment for new chest pain — RN

• A. RN: Correct: initial assessment requires RN judgment.
• B. Trained UAP: Unsafe to delegate assessment.

Routine bathing of a stable patient — Trained UAP

• A. RN: RN can perform it, but delegation may be appropriate.
• B. Trained UAP: Correct when trained, supervised and permitted.

Initial medication teaching — RN

• A. RN: Correct: initial teaching and evaluation require RN judgment.
• B. Trained UAP: UAP should not independently provide initial teaching.

SpO₂ 82% and new dyspnea — Urgent

• A. Urgent: Correct: acute oxygenation failure.
• B. Routine: Unsafe delay.

Old unchanged surgical scar — Routine

• A. Urgent: Not acute.
• B. Routine: Correct: stable historical finding.

BP 78/42 and new confusion — Urgent

• A. Urgent: Correct: possible shock.
• B. Routine: Unsafe delay.

Pulmonary tuberculosis — Airborne

• A. Airborne: Correct: airborne precautions.
• B. Droplet: Not sufficient alone.
• C. Contact: Not routinely required without another indication.

Seasonal influenza — Droplet

• A. Airborne: Not routine for uncomplicated influenza.
• B. Droplet: Correct: droplet precautions.
• C. Contact: Not standard unless other indications.

C. difficile diarrhea — Contact

• A. Airborne: Not routine.
• B. Droplet: Not routine.
• C. Contact: Correct: contact precautions and appropriate hand hygiene.

New unilateral leg swelling and tenderness — Prompt assessment and escalation, Avoid massaging affected leg

• A. Prompt assessment and escalation: Correct: possible DVT.
• B. Massage affected leg: Massage may be hazardous.
• C. Avoid massaging affected leg: Correct: avoid manipulation.

Sudden severe chest pain with diaphoresis — Prompt assessment and escalation

• A. Prompt assessment and escalation: Correct: potential acute coronary syndrome.
• B. Massage affected leg: Unrelated.
• C. Delay assessment: Unsafe delay.

Likely condition • select one — Pulmonary edema

• A. Pulmonary edema: Correct: acute respiratory fluid overload.
• B. UTI: Does not fit.
• C. Stable arthritis: Unrelated.

Priority actions • select two — Support oxygenation; position appropriately, Urgently escalate and prepare prescribed therapy

• A. Support oxygenation; position appropriately: Correct: support breathing.
• B. Urgently escalate and prepare prescribed therapy: Correct: prompt treatment.
• C. Give large fluid bolus: May worsen congestion.
• D. Wait an hour: Unsafe.

Monitor • select two — SpO₂ and work of breathing, BP and response to therapy

• A. SpO₂ and work of breathing: Correct: respiratory response.
• B. BP and response to therapy: Correct: perfusion and treatment response.
• C. Hair growth: Not relevant.
• D. Shoe size: Not relevant.

Most likely condition • select one — Acute hypoglycemia

• A. Acute hypoglycemia: Correct: low glucose with symptoms.
• B. Stable hyperglycemia: Glucose is low.
• C. Tension headache: Does not explain glucose.

Priority actions • select two — Protect airway; call for help, Protocol-directed non-oral glucose rescue

• A. Protect airway; call for help: Correct: prevent aspiration.
• B. Protocol-directed non-oral glucose rescue: Correct: urgent nonoral rescue.
• C. Give juice despite unsafe swallow: Aspiration risk.
• D. Wait for scheduled round: Unsafe delay.

Monitor • select two — Repeat glucose, Consciousness and airway

• A. Repeat glucose: Correct: response to therapy.
• B. Consciousness and airway: Correct: neurological and airway safety.
• C. Hair texture: Not priority.
• D. Favorite foods: Not relevant.

An SpO₂ of 82% with severe dyspnea needs — urgent respiratory assessment

• A. urgent respiratory assessment: Correct: urgent.
• B. routine discharge teaching: Not first.
• C. review next week: Unsafe.

The RN should prioritize — airway and breathing

• A. airway and breathing: Correct: ABCs.
• B. future activity planning: Later.
• C. routine records: Not acute.

Severe hypokalemia increases risk for — dysrhythmia

• A. dysrhythmia: Correct: cardiac effects.
• B. normal conduction: Not normal.
• C. inevitable hyperglycemia: Not the main consequence.

The RN prioritizes — cardiac assessment and ordered safe replacement

• A. cardiac assessment and ordered safe replacement: Correct: safe care.
• B. unmonitored high-dose replacement: Unsafe.
• C. waiting a shift: Unsafe delay.

Firm uterus, expected lochia, stable vitals — Routine monitor

• A. Routine monitor: Correct: monitor trend.
• B. Urgent escalation: No emergency indicated alone.

Boggy uterus with heavy bleeding — Urgent escalation

• A. Routine monitor: Unsafe: possible atony.
• B. Urgent escalation: Correct: hemorrhage warning.

New dizziness, HR 132, falling BP — Urgent escalation

• A. Routine monitor: Unsafe.
• B. Urgent escalation: Correct: possible shock.

Glucose 49 mg/dL, new confusion — Urgent hypoglycemia treatment

• A. Urgent hypoglycemia treatment: Correct: immediate rescue.
• B. Routine follow-up: Unsafe delay.

Glucose 108 mg/dL, asymptomatic — Routine follow-up

• A. Urgent hypoglycemia treatment: No hypoglycemia evident.
• B. Routine follow-up: Correct: no emergent low-glucose signs.

Correct answer: B, C, E

1. 70-year-old patient. Age alone is not the acute change.
2. New confusion. Correct: altered mentation.
3. SpO₂ falls from 96% to 84%. Correct: acute desaturation.
4. Old healed ankle scar. Historical and unchanged.
5. Respiratory rate 34/min. Correct: tachypnea.
6. Favorite food is soup. Unrelated.

Correct answer: A, B

1. New HR 138/min with dizziness. Correct: possible blood loss.
2. BP 80/44 mmHg. Correct: marked hypotension.
3. Healed incision. Not a new perfusion sign.
4. Requested blanket. Not a specific perfusion cue.
5. Routine lunch preference. Not relevant.

Correct answer: Protect the person from injury; summon help → Monitor airway, breathing and oxygenation → Reassess neurological recovery → Document the event after stabilization

1. Document the event after stabilization. Documentation follows stabilization.
2. Protect the person from injury; summon help. First: protect and call; never restrain.
3. Monitor airway, breathing and oxygenation. Assess ABCs as safely as possible.
4. Reassess neurological recovery. Reassess following the event.

Correct answer: Stop the transfusion → Assess ABCs and call urgently; maintain access as protocol directs → Notify prescriber and blood bank; follow reaction protocol → Document response and follow-up

1. Stop the transfusion. First: stop the suspected causative product.
2. Assess ABCs and call urgently; maintain access as protocol directs. Next: protect airway/circulation and escalate.
3. Notify prescriber and blood bank; follow reaction protocol. Complete institutional reaction notifications.
4. Document response and follow-up. Record and follow up after response.

Delegation depends on training, patient stability, jurisdiction and policy.

Initial assessment of new dyspnea — RN-led

• A. RN-led: Correct: requires nursing judgment.
• B. May delegate to trained UAP: Not appropriate.

Routine bed-making in stable care — May delegate to trained UAP

• A. RN-led: RN may perform it but delegation is possible.
• B. May delegate to trained UAP: Correct where policy permits.

Evaluate response to new medication — RN-led

• A. RN-led: Correct: requires RN evaluation.
• B. May delegate to trained UAP: Not appropriate.

New stridor — Immediate threat

• A. Immediate threat: Correct: airway threat.
• B. Routine background: Unsafe delay.

Old unchanged birthmark — Routine background

• A. Immediate threat: Not acute.
• B. Routine background: Correct.

New unilateral weakness and slurred speech — Immediate threat

• A. Immediate threat: Correct: suspected stroke.
• B. Routine background: Unsafe delay.

SpO₂ rises from 87% to 95% — Improving

• A. Improving: Correct: better oxygenation with continued monitoring.
• B. Deteriorating: Not worsening.

Work of breathing worsens with exhaustion — Deteriorating

• A. Improving: Unsafe classification.
• B. Deteriorating: Correct: fatigue may precede respiratory failure.

Patient can speak in full sentences — Improving

• A. Improving: Correct: reassuring respiratory function.
• B. Deteriorating: Not deterioration.

Confusion resolves and patient is oriented — Improving

• A. Improving: Correct: improvement.
• B. Worsening: Not worsening.

BP falls from 94/58 to 76/40 mmHg — Worsening

• A. Improving: Unsafe: hypotension worse.
• B. Worsening: Correct: worsening perfusion.

Urine output increases from 10 to 40 mL/h with improved perfusion — Improving

• A. Improving: Correct: reassuring trend.
• B. Worsening: Not worsening alone.

Patient record A: 30 minutes after vaginal birth: boggy uterus, heavy bleeding, HR 124/min, BP 92/56, pallor. Follow emergency obstetric protocols.

Correct answer: A, B, D

1. Boggy uterus. Correct: atony cue.
2. Heavy vaginal bleeding. Correct: blood loss.
3. Warm blanket preference. Not urgent.
4. Heart rate 124/min. Correct: may indicate hypovolemia.
5. Old ankle scar. Not acute.

Patient record A: 30 minutes after vaginal birth: boggy uterus, heavy bleeding, HR 124/min, BP 92/56, pallor. Follow emergency obstetric protocols.

Correct answer: B

1. Normal lochia. Heavy bleeding and poor tone are not expected.
2. Postpartum hemorrhage related to uterine atony. Correct: atony may cause hemorrhage.
3. Stable old anemia. Does not explain active blood loss.
4. Normal uterine involution. Normal involution produces a firm fundus.

Patient record A: 30 minutes after vaginal birth: boggy uterus, heavy bleeding, HR 124/min, BP 92/56, pallor. Follow emergency obstetric protocols.

Correct answer: C

1. Sleep schedule. Lower priority.
2. Routine teaching. Later.
3. Compromised circulation from blood loss. Correct: hemorrhage threatens perfusion.
4. Discharge paperwork. Not appropriate now.

Patient record A: 30 minutes after vaginal birth: boggy uterus, heavy bleeding, HR 124/min, BP 92/56, pallor. Follow emergency obstetric protocols.

Correct answer: A, B

1. Activate obstetric hemorrhage response. Correct: urgent team response.
2. Fundal massage according to protocol for a boggy uterus. Correct: first-line action in suspected atony per protocol.
3. Leave the patient alone. Unsafe.
4. Encourage unassisted walking. Unsafe during bleeding.

Patient record A: 30 minutes after vaginal birth: boggy uterus, heavy bleeding, HR 124/min, BP 92/56, pallor. Follow emergency obstetric protocols.

Correct answer: B

1. Only document. Insufficient.
2. Follow hemorrhage pathway, assess ABCs and support prescribed resuscitation. Correct: coordinate emergency treatment.
3. Wait for next round. Unsafe delay.
4. Prepare discharge. Unsafe.

Patient record A: 30 minutes after vaginal birth: boggy uterus, heavy bleeding, HR 124/min, BP 92/56, pallor. Follow emergency obstetric protocols.

Uterus firms and bleeding decreases — Improving

• A. Improving: Correct: favorable response.
• B. Concerning: Not worsening by itself.

BP falls to 76/40, new confusion — Concerning

• A. Improving: Unsafe.
• B. Concerning: Correct: perfusion deterioration.

HR trends toward baseline as perfusion improves — Improving

• A. Improving: Correct: reassuring trend.
• B. Concerning: Not itself deterioration.

Patient record B: Acute kidney injury, K⁺ 6.5 mmol/L, peaked T waves, HR 54/min, weakness and reduced urine output. Follow emergency treatment orders.

Correct answer: B, D, E

1. Old allergic rhinitis. Not acute.
2. K⁺ 6.5 mmol/L. Correct: dangerous hyperkalemia.
3. Healed scar. Not acute.
4. Peaked T waves. Correct: ECG change.
5. HR 54/min with weakness. Correct: potential cardiac compromise.

Patient record B: Acute kidney injury, K⁺ 6.5 mmol/L, peaked T waves, HR 54/min, weakness and reduced urine output. Follow emergency treatment orders.

Correct answer: C

1. Normal aging. Does not explain high K.
2. Stable constipation. Not priority.
3. Electrical cardiac instability from severe hyperkalemia. Correct: lethal arrhythmia risk.
4. Mild dehydration with no ECG implications. ECG changes indicate danger.

Patient record B: Acute kidney injury, K⁺ 6.5 mmol/L, peaked T waves, HR 54/min, weakness and reduced urine output. Follow emergency treatment orders.

Correct answer: B

1. Long-term exercise plan. Later.
2. Life-threatening dysrhythmia. Correct: immediate cardiac risk.
3. Routine diet preference. Later.
4. Physiotherapy schedule. Later.

Patient record B: Acute kidney injury, K⁺ 6.5 mmol/L, peaked T waves, HR 54/min, weakness and reduced urine output. Follow emergency treatment orders.

Correct answer: A, B

1. Start cardiac monitoring. Correct: monitor electrical activity.
2. Escalate urgently and prepare ordered hyperkalemia treatments. Correct: emergency protocol.
3. Give potassium supplement. Worsens condition.
4. Wait for next shift. Unsafe.

Patient record B: Acute kidney injury, K⁺ 6.5 mmol/L, peaked T waves, HR 54/min, weakness and reduced urine output. Follow emergency treatment orders.

Correct answer: A

1. Administer ordered therapy via correct route using medication checks and monitoring. Correct: IV calcium may stabilize myocardium; follow protocol.
2. Give oral potassium instead. Unsafe.
3. Wait an hour. Unsafe delay.
4. Give medications without verifying orders. Never skip verification.

Patient record B: Acute kidney injury, K⁺ 6.5 mmol/L, peaked T waves, HR 54/min, weakness and reduced urine output. Follow emergency treatment orders.

ECG changes improve and rhythm stabilizes — Improving

• A. Improving: Correct: monitor and repeat labs.
• B. Worsening: Not worsening.

QRS widens with falling BP — Worsening

• A. Improving: Unsafe interpretation.
• B. Worsening: Correct: cardiac deterioration.

Repeat K⁺ trends toward normal and weakness improves — Improving

• A. Improving: Correct: response to therapy.
• B. Worsening: Not worsening.

Correct answer: B.

1. Offer routine discharge teaching. Education cannot replace urgent respiratory support.
2. Remain with the patient, assess breathing and urgently escalate for protocol-directed treatment. Correct: severe distress can progress to respiratory failure.
3. Ask the patient to walk to improve airflow. Activity increases respiratory demand.
4. Wait for the next scheduled peak-flow measurement. Delaying assessment is unsafe.

Correct answer: C.

1. Document and wait until the next imaging round. Acute respiratory compromise demands immediate evaluation.
2. Give oral water. Fluids do not address suspected pneumothorax.
3. Call for urgent help, assess ABCs, and prepare for prompt evaluation and prescribed intervention. Correct: sudden unilateral breath-sound loss is a serious complication.
4. Position flat and leave the patient alone. May worsen breathing and delays support.

Correct answer: A.

1. Assess ABCs and vital signs, activate the chest-pain pathway and obtain prompt ordered ECG. Correct: potential acute coronary syndrome needs immediate evaluation.
2. Provide an antacid without assessment. This could mask or delay recognition of myocardial ischemia.
3. Ask the patient to finish lunch first. Delay is unsafe.
4. Schedule routine education for tomorrow. Not an immediate response.

Correct answer: D.

1. Offer a large meal. Unsafe with suspected hemorrhage.
2. Recheck BP after an hour. Shock findings demand immediate intervention.
3. Ask about preferred food choices. Not urgent.
4. Activate urgent assistance, assess circulation and prepare ordered resuscitation support. Correct: hypotension with hematemesis suggests major blood loss.

Correct answer: B.

1. Elevate the limb well above heart level and postpone review. This may further compromise perfusion and delays evaluation.
2. Urgently assess neurovascular status and notify the treating team for possible compartment syndrome. Correct: escalating pain and passive-stretch pain are red flags.
3. Encourage ambulation to loosen the cast. Unsafe.
4. Apply heat over the cast. Does not treat compartment syndrome.

Correct answer: C.

1. Start insulin regardless of the potassium level. Insulin can worsen hypokalemia.
2. Administer routine oral sweets. Not an appropriate DKA treatment.
3. Promptly report low potassium and prepare prescribed potassium correction before insulin as ordered. Correct: significant hypokalemia must be addressed to prevent arrhythmias.
4. Wait for the next shift. Unsafe delay.

Correct answer: D.

1. Give the drug as scheduled. Symptomatic bradycardia may be unsafe.
2. Double the following dose. Potentially harmful.
3. Ask the patient to exercise. This will not safely address bradycardia.
4. Hold administration pending prompt assessment and prescriber notification according to orders/policy. Correct: significant bradycardia requires evaluation before digoxin.

Correct answer: A.

1. Support airway and breathing, summon emergency assistance and prepare ordered reversal treatment. Correct: opioid-associated respiratory depression is life-threatening.
2. Give the next opioid dose. May worsen respiratory depression.
3. Document the finding for morning rounds. Dangerous delay.
4. Encourage the patient to walk alone. Unsafe.

Correct answer: C.

1. Increase the oxytocin infusion. May intensify uterine tachysystole.
2. Continue and reassess in one hour. Delay threatens fetal oxygenation.
3. Stop oxytocin, reposition, assess and urgently notify the obstetric team per protocol. Correct: reduce uterine stimulation and initiate intrauterine resuscitation.
4. Encourage unassisted ambulation. Not the priority.

Correct answer: B.

1. Use a tongue depressor to inspect the throat. May precipitate complete obstruction in suspected epiglottitis.
2. Keep the child calm, avoid throat manipulation and call the emergency airway team. Correct: potential supraglottic obstruction requires expert airway management.
3. Force oral fluids. Aspiration and airway risk.
4. Send the child to routine waiting room observation. Unsafe delay.

Correct answer: A.

1. Maintain patient safety, stay with them and initiate immediate suicide-risk assessment and emergency precautions. Correct: a specific plan requires urgent safety measures.
2. Promise confidentiality. Safety threats may require sharing with the care team.
3. Tell them to stop thinking negatively. Dismisses risk.
4. Leave them alone to rest. Increases danger.

Correct answer: D.

1. Assume this is expected anxiety. The clinical cluster suggests a serious reaction.
2. Give another serotonergic medication. May worsen toxicity.
3. Wait for a routine review next week. Dangerous delay.
4. Urgently assess, stop further serotonergic dosing pending orders and activate escalation for suspected serotonin syndrome. Correct: early recognition and supportive treatment are critical.

Correct answer: A, B, D, F.

1. Support upright positioning as tolerated. Correct: can ease breathing.
2. Monitor oxygenation and respiratory effort. Correct: tracks acute status.
3. Encourage unrestricted large-volume fluid intake. May worsen congestion.
4. Review fluid balance and urine output. Correct: evaluates response and fluid status.
5. Delay escalation until a routine outpatient review. Unsafe.
6. Prepare ordered treatment and promptly notify the team of deterioration. Correct: timely care is required.

Correct answer: B, C, E.

1. Skip all blood glucose checks. Unsafe: monitoring is essential.
2. Carry a quick-acting carbohydrate source. Correct: supports timely treatment if able to swallow.
3. Review meal timing, activity and insulin regimen with the care team. Correct: identify triggers.
4. Change insulin doses independently without guidance. Risk of further hypoglycemia.
5. Teach family to recognize and respond to severe hypoglycemia. Correct: emergency readiness.
6. Drive a vehicle while confused. Unsafe.

Correct answer: A, B, C, E.

1. Report unusual bleeding, black stools or severe headache. Correct: may indicate hemorrhage.
2. Follow the prescribed INR monitoring schedule. Correct: helps assess anticoagulation.
3. Keep dietary vitamin K intake reasonably consistent. Correct: abrupt changes can affect anticoagulation.
4. Take aspirin or NSAIDs without checking with the prescriber. May raise bleeding risk.
5. Inform clinicians and pharmacists about warfarin before new medicines. Correct: interactions matter.
6. Double the next dose after forgetting one. Unsafe unless specifically directed.

Correct answer: B, C, E, F.

1. Remain in bed without moving for several days. Immobility increases risk.
2. Perform prescribed early mobilization and leg exercises. Correct when clinically permitted.
3. Use prescribed mechanical prophylaxis correctly. Correct: helps reduce venous stasis.
4. Massage a painful swollen calf. Unsafe if DVT is suspected.
5. Administer prescribed prophylactic anticoagulant with bleeding assessment. Correct: follow orders and safety checks.
6. Report new unilateral leg swelling or sudden dyspnea. Correct: may indicate VTE.

Correct answer: B, C, D, F.

1. Offer oral water before assessing swallowing. Aspiration risk.
2. Activate the stroke response system immediately. Correct: time-critical care.
3. Determine last-known-well time. Correct: guides treatment eligibility.
4. Assess airway, glucose, vital signs and neurologic status. Correct: excludes mimics and identifies instability.
5. Delay evaluation to see if deficits disappear. Unsafe.
6. Keep the patient NPO until swallowing safety is assessed according to protocol. Correct: prevents aspiration.

Correct answer: A, C, E.

1. Urgently assess fever using institutional thresholds. Correct: infection may become life-threatening rapidly.
2. Rely on visible pus as the only sign of infection. Neutropenia may blunt inflammation.
3. Perform hand hygiene and use appropriate infection precautions. Correct: prevention.
4. Allow visitors with fever to enter unprotected. Unsafe infection exposure.
5. Assess oral mucosa and catheter sites for infection. Correct: common entry points.
6. Delay notification of hypotension until morning. Unsafe.

Correct answer: A, B, D, E.

1. Severe persistent headache. Correct: possible neurologic involvement.
2. New visual disturbances. Correct: severe-feature warning sign.
3. Mild, unchanged stretching discomfort in the legs. Not specific for severe preeclampsia.
4. New right upper quadrant or epigastric pain. Correct: possible hepatic involvement.
5. Sudden shortness of breath. Correct: possible pulmonary edema.
6. Normal appetite earlier that morning. Not a severe-feature cue.

Correct answer: B, C, E, F.

1. Tell the patient the voices are definitely real. Reinforces hallucination as external reality.
2. Ask whether the voices command the patient to harm themselves or others. Correct: assess safety.
3. State that you do not hear the voices while acknowledging the distress. Correct: reality-oriented empathy.
4. Ridicule the belief. Damages trust.
5. Reduce environmental stimulation and offer supportive presence. Correct: may help reduce distress.
6. Assess safety and follow escalation policy for dangerous command content. Correct: urgent risk management.

Correct answer: A, C, D.

1. New confusion. Correct: altered mental state may reflect dysfunction.
2. Stable old foot callus. Not acute.
3. Blood pressure 82/46 mmHg. Correct: hypotension suggests hypoperfusion.
4. Urine output 12 mL in the preceding hour. Correct: possible renal hypoperfusion.
5. Unchanged seasonal allergies. Not relevant.
6. Favorite meal is rice. Not relevant.

Correct answer: A, C.

1. New exhaustion with reduced respiratory effort. Correct: respiratory fatigue is dangerous.
2. Talking comfortably in complete sentences. Reassuring relative to severe distress.
3. New decreasing level of consciousness. Correct: possible worsening hypoxia or hypercapnia.
4. Warm hands after a blanket. Not an emergency cue.
5. Stable unchanged mild cough. Not enough to indicate impending failure.

Correct answer: A, B, D.

1. Coarse tremor. Correct: neurologic warning sign.
2. New ataxia. Correct: concerning toxicity cue.
3. Stable mild thirst already discussed with prescriber. May occur but alone is less concerning than neurologic deterioration.
4. Severe diarrhea and vomiting. Correct: may worsen dehydration and lithium toxicity.
5. Normal appetite. Not a toxicity warning.
6. Unchanged freckles. Unrelated.

Correct answer: A, C.

1. New tachycardia and pallor. Correct: possible hypovolemia.
2. Firm uterus and light expected lochia. Relatively reassuring findings.
3. Persistent heavy vaginal bleeding. Correct: hemorrhage cue.
4. Normal uterine afterpains. Expected without other danger signs.
5. Stable blood pressure at previous baseline. Not by itself a loss indicator.

Correct answer: A, B, D.

1. Potassium 6.6 mmol/L. Correct: dangerous degree of elevation.
2. New widened QRS complex. Correct: electrical instability.
3. Old uncomplicated eczema. Irrelevant.
4. New symptomatic bradycardia. Correct: possible conduction impairment.
5. Unchanged eyeglass prescription. Irrelevant.

Correct answer: A, C.

1. New chest pain, fever and low oxygen saturation. Correct: possible acute chest syndrome.
2. Usual school-day fatigue without new symptoms. Not the urgent pattern.
3. New focal weakness and speech change. Correct: possible stroke.
4. Stable mild dry skin. Not urgent.
5. Unchanged old healed scar. Not urgent.

Assume appropriately trained UAP; follow jurisdiction and policy.

Initial assessment of new unilateral weakness — RN

• A. RN: Correct: initial neurologic assessment requires nursing judgment.
• B. Trained UAP: Cannot perform the RN assessment.

Help a stable patient brush their teeth — Trained UAP

• A. RN: RN may assist, but this routine task is delegable.
• B. Trained UAP: Correct if permitted and supervised.

Evaluate effectiveness of new pain medication — RN

• A. RN: Correct: evaluation requires RN assessment.
• B. Trained UAP: Cannot independently evaluate therapy.

Respiratory rate 6/min and difficult to arouse — Urgent escalation

• A. Urgent escalation: Correct: possible opioid respiratory depression.
• B. Routine monitoring: Unsafe delay.

Alert, RR 16/min, stable oxygenation — Routine monitoring

• A. Urgent escalation: No danger cue presented.
• B. Routine monitoring: Correct: continue surveillance.

New apnea spells — Urgent escalation

• A. Urgent escalation: Correct: critical breathing threat.
• B. Routine monitoring: Unsafe delay.

Angioedema after first ACE inhibitor dose — Urgent escalation

• A. Urgent escalation: Correct: airway edema can progress rapidly.
• B. Routine teaching: Unsafe delay.

Mild expected increased urination after prescribed diuretic — Routine teaching

• A. Urgent escalation: Not necessarily emergent alone.
• B. Routine teaching: Correct if otherwise stable.

New severe hypotension and fainting after antihypertensive — Urgent escalation

• A. Urgent escalation: Correct: perfusion risk.
• B. Routine teaching: Not sufficient.

No urine for 10 hours and lethargy — Concerning

• A. Concerning: Correct: possible significant dehydration.
• B. Reassuring: Unsafe assessment.

Alert, drinking and urinating regularly — Reassuring

• A. Concerning: Not the described presentation.
• B. Reassuring: Correct: positive hydration indicators.

Sunken eyes, weak pulses and delayed capillary refill — Concerning

• A. Concerning: Correct: poor perfusion.
• B. Reassuring: Unsafe assessment.

Suspected pulmonary tuberculosis — Airborne

• A. Airborne: Correct: respirator and appropriate room.
• B. Droplet: Insufficient alone.

Seasonal influenza without aerosol-generating procedures — Droplet

• A. Airborne: Not routine for this scenario.
• B. Droplet: Correct: follow droplet precautions.

Active Clostridioides difficile diarrhea — Contact

• A. Contact: Correct: enteric/contact precautions.
• B. Droplet: Does not address organism transmission.

New orthopnea and crackles — Assess respiratory status and oxygenation, Review fluid balance

• A. Assess respiratory status and oxygenation: Correct: detect deterioration.
• B. Review fluid balance: Correct: helps assess congestion.
• C. Encourage unrestricted fluids: Can worsen overload.

New dizziness and systolic BP 78 mmHg — Urgently reassess perfusion, Notify urgent response team per policy

• A. Urgently reassess perfusion: Correct: significant hypotension.
• B. Notify urgent response team per policy: Correct: possible shock.
• C. Delay care until morning: Unsafe.

Alert and safely swallowing with glucose 58 mg/dL — Follow protocol for fast-acting oral glucose, Recheck glucose according to protocol

• A. Follow protocol for fast-acting oral glucose: Correct when swallowing is safe.
• B. Recheck glucose according to protocol: Correct: evaluate response.
• C. Give long-acting insulin without assessment: Unsafe in active hypoglycemia.

Unresponsive, glucose 41 mg/dL — Protect airway and summon urgent help, Prepare prescribed nonoral rescue therapy

• A. Protect airway and summon urgent help: Correct: neurologic emergency.
• B. Give oral juice by mouth: Aspiration risk.
• C. Prepare prescribed nonoral rescue therapy: Correct: immediate rescue.

Initial evaluation — Assess ABCs and vital signs, Obtain urgent ordered ECG

• A. Assess ABCs and vital signs: Correct: determine instability.
• B. Obtain urgent ordered ECG: Correct: evaluate cardiac ischemia.
• C. Ask patient to exercise: Unsafe.

Safety planning — Escalate promptly to clinical team, Continue symptom reassessment

• A. Escalate promptly to clinical team: Correct: time-critical.
• B. Give unprescribed medication automatically: Follow orders and assess contraindications.
• C. Continue symptom reassessment: Correct: monitor progression.

Tight cast, increasing pain and new paresthesia — Urgently escalate possible compartment syndrome, Assess neurovascular findings

• A. Urgently escalate possible compartment syndrome: Correct: limb-threatening.
• B. Assess neurovascular findings: Correct: monitor distal circulation and nerves.
• C. Use intense heat treatment: Unsafe.

Hand is pale and pulseless after vascular access — Urgent assessment and escalation, Recheck circulation and sensation immediately

• A. Urgent assessment and escalation: Correct: possible ischemia.
• B. Recheck circulation and sensation immediately: Correct: evaluate compromise.
• C. Tell patient to return next week: Unsafe.

Most likely concern • one — Acute stroke

• A. Acute stroke: Correct: sudden focal deficits.
• B. Chronic joint disease: Does not fit.
• C. Stable vertigo without deficits: Does not fit.

Priority actions • two — Activate stroke response and note last-known-well time, Assess ABCs, bedside glucose and neurologic status

• A. Activate stroke response and note last-known-well time: Correct: time-sensitive stroke pathway.
• B. Assess ABCs, bedside glucose and neurologic status: Correct: safety and stroke-mimic assessment.
• C. Offer a snack without swallowing screen: Aspiration risk.
• D. Wait for symptoms to resolve: Unsafe.

Monitor • two — Neurologic changes and level of consciousness, Vital signs and airway/oxygenation

• A. Neurologic changes and level of consciousness: Correct: track worsening.
• B. Vital signs and airway/oxygenation: Correct: detect instability.
• C. Hair color: Not relevant.
• D. Footwear preference: Not relevant.

Most likely condition • one — Anaphylaxis

• A. Anaphylaxis: Correct: skin, airway and circulatory findings.
• B. Simple itch without systemic involvement: Does not fit hypotension.
• C. Stable medication intolerance: Does not explain shock.

Priority actions • two — Stop suspected trigger and activate emergency response, Prepare/administer protocol-directed IM epinephrine and support airway

• A. Stop suspected trigger and activate emergency response: Correct: immediate help.
• B. Prepare/administer protocol-directed IM epinephrine and support airway: Correct: first-line rescue.
• C. Wait for oral antihistamine alone: Insufficient for anaphylaxis.
• D. Leave patient unattended: Unsafe.

Monitor • two — Airway, work of breathing and SpO₂, Blood pressure, pulse and response to treatment

• A. Airway, work of breathing and SpO₂: Correct: airway status.
• B. Blood pressure, pulse and response to treatment: Correct: shock response.
• C. Appetite next month: Not acute.
• D. Shoe size: Not acute.

Most likely concern • one — Acute severe asthma exacerbation

• A. Acute severe asthma exacerbation: Correct: airflow obstruction and hypoxemia.
• B. Stable seasonal allergies only: Not adequate explanation.
• C. Simple tension headache: Unrelated.

Priority actions • two — Urgent airway/breathing assessment and assistance, Prepare prescribed rapid bronchodilator and oxygen support

• A. Urgent airway/breathing assessment and assistance: Correct: respiratory threat.
• B. Prepare prescribed rapid bronchodilator and oxygen support: Correct: protocol-directed care.
• C. Encourage unassisted exertion: Unsafe.
• D. Wait for next clinic visit: Unsafe.

Monitor • two — Respiratory effort and ability to speak, SpO₂, mental status and treatment response

• A. Respiratory effort and ability to speak: Correct: work of breathing.
• B. SpO₂, mental status and treatment response: Correct: deterioration surveillance.
• C. Long-term hair growth: Not relevant.
• D. Favorite food: Not relevant.

Suspected urgent complication — pulmonary embolism

• A. pulmonary embolism: Correct: sudden dyspnea after surgery is concerning.
• B. chronic arthritis: Does not explain presentation.
• C. stable seasonal rhinitis: Not adequate explanation.

The RN priority is — urgent respiratory assessment and escalation

• A. urgent respiratory assessment and escalation: Correct: assess and promptly seek help.
• B. encouraging the patient to walk alone: Unsafe.
• C. waiting an hour: Unsafe delay.

Highest immediate priority — support airway and breathing

• A. support airway and breathing: Correct: respiratory support is first.
• B. routine paperwork: Not urgent.
• C. ambulation: Unsafe.

Medication preparation — prescribed naloxone per protocol

• A. prescribed naloxone per protocol: Correct: reversal may be indicated.
• B. additional opioid: Could worsen depression.
• C. oral sedatives: Could worsen sedation.

Priority hypothesis — possible gastrointestinal bleeding

• A. possible gastrointestinal bleeding: Correct: melena with symptoms suggests hemorrhage.
• B. uncomplicated constipation: Does not explain melena.
• C. expected harmless effect: Unsafe assumption.

Priority action — assess perfusion, prevent injury and urgently escalate

• A. assess perfusion, prevent injury and urgently escalate: Correct: signs of bleeding need immediate assessment.
• B. administer next warfarin dose automatically: May worsen hemorrhage.
• C. delay evaluation: Unsafe.

New hypotension and decreasing urine output — Concerning deterioration

• A. Concerning deterioration: Correct: possible hypoperfusion.
• B. Routine expected finding: Unsafe.

Increasing urine output with stable BP and improved mentation — Improvement to monitor

• A. Concerning deterioration: Not the described pattern.
• B. Improvement to monitor: Correct: reassuring perfusion trend.

New respiratory distress after enclosed-space fire — Concerning deterioration

• A. Concerning deterioration: Correct: possible inhalation injury.
• B. Routine expected finding: Unsafe.

Premeal glucose 52 mg/dL with sweating — Treat hypoglycemia per protocol

• A. Treat hypoglycemia per protocol: Correct: symptomatic low glucose.
• B. Give routine rapid-acting insulin before assessment: May worsen hypoglycemia.

Glucose 118 mg/dL, awake, meal present and medication order verified — Proceed with ordered care and monitoring

• A. Urgent hypoglycemia treatment: No hypoglycemia indicated.
• B. Proceed with ordered care and monitoring: Correct: continue safe medication checks.

New altered consciousness; glucose 43 mg/dL and unsafe swallowing — Urgent nonoral rescue per protocol

• A. Urgent nonoral rescue per protocol: Correct: airway safety.
• B. Give oral juice immediately: Aspiration risk.

Persistent heavy bleeding and boggy fundus — Urgent

• A. Urgent: Correct: likely uterine atony/hemorrhage.
• B. Routine: Unsafe.

Firm fundus, normal lochia, stable HR/BP — Routine monitoring

• A. Urgent: No red flag by itself.
• B. Routine monitoring: Correct: continue trend assessment.

New severe headache, vision changes and BP 172/112 — Urgent

• A. Urgent: Correct: possible severe preeclampsia postpartum.
• B. Routine: Unsafe.

Correct answer: A, C, E.

1. New BP 80/44 mmHg. Correct: severe hypotension.
2. Old healed scar. Not acute.
3. New confusion. Correct: possible hypoperfusion.
4. Routine dinner order. Not acute.
5. Urine output 10 mL in one hour. Correct: possible renal hypoperfusion.
6. Favorite television channel. Not relevant.

Correct answer: B, D.

1. Normal school preference. Not relevant.
2. New chest pain with fever. Correct: possible acute chest syndrome.
3. Unchanged dry skin. Not emergency.
4. SpO₂ 86% with increased breathing effort. Correct: hypoxemia.
5. An old healed foot scar. Not acute.

Correct answer: A, C, D.

1. New wheezing. Correct: airway involvement.
2. Stable long-standing myopia. Irrelevant.
3. Generalized hives. Correct: systemic hypersensitivity.
4. BP 76/42 mmHg. Correct: cardiovascular collapse.
5. Previous unchanged toenail injury. Not acute.
6. Normal appetite yesterday. Not relevant.

Correct answer: Assess airway and call for urgent help → Administer ordered/protocol-directed nonoral rescue treatment → Repeat glucose and evaluate consciousness according to protocol → Document treatment and monitor for recurrence.

1. Document treatment and monitor for recurrence. Last: documentation after stabilization.
2. Assess airway and call for urgent help. First: immediate safety and assistance.
3. Administer ordered/protocol-directed nonoral rescue treatment. Next: treat low glucose safely.
4. Repeat glucose and evaluate consciousness according to protocol. Then: determine response.

Correct answer: Stop transfusion immediately → Assess ABCs, urgently escalate and maintain IV access with appropriate saline/tubing per policy → Notify provider and blood bank; follow reaction workup → Document and monitor after intervention.

1. Notify provider and blood bank; follow reaction workup. After immediate stabilization.
2. Stop transfusion immediately. First: remove potential trigger.
3. Assess ABCs, urgently escalate and maintain IV access with appropriate saline/tubing per policy. Next: support life functions.
4. Document and monitor after intervention. Last: follow up.

Scope varies by state, institution and patient stability.

Initial nursing assessment — RN

• A. RN: Correct: requires professional judgment.
• B. Trained UAP: Cannot perform initial RN assessment.

Assist stable patient with toileting — Trained UAP

• A. RN: RN may help but task can be delegated.
• B. Trained UAP: Correct when permitted and supervised.

Reassess patient after IV analgesia — RN

• A. RN: Correct: response evaluation requires clinical judgment.
• B. Trained UAP: Cannot independently reassess therapy.

This is a simplified educational triage scenario; follow jurisdictional incident-command protocols.

Severe uncontrolled external bleeding — Immediate

• A. Immediate: Correct: life-threatening hemorrhage.
• B. Lower priority: Unsafe.

Minor abrasion and stable vital signs — Lower priority

• A. Immediate: Higher acuity patients require care first.
• B. Lower priority: Correct: stable minor injury.

Airway obstruction with respiratory distress — Immediate

• A. Immediate: Correct: airway threat.
• B. Lower priority: Unsafe.

Respiratory rate falls from 38/min to 20/min with improved comfort — Improvement

• A. Improvement: Correct: reassuring with other markers.
• B. Deterioration: Not by itself.

Mental status becomes progressively drowsy — Deterioration

• A. Improvement: Dangerous assumption.
• B. Deterioration: Correct: possible respiratory failure.

SpO₂ rises from 85% to 95% while work of breathing decreases — Improvement

• A. Improvement: Correct: reassuring trend.
• B. Deterioration: Not in this context.

Case C — Pediatric dehydration: A 2-year-old with diarrhea and vomiting has poor oral intake, dry mucosa, very few wet diapers and new lethargy. HR 158/min; capillary refill 4 seconds. The clinical team is assessing possible hypovolemia; follow pediatric fluid protocols.

Correct answer: A, B, D.

1. Delayed capillary refill of 4 seconds. Correct: poor peripheral perfusion.
2. Dry oral mucosa. Correct: potential fluid deficit.
3. Favorite toy is a teddy bear. Not relevant.
4. Markedly decreased wet diapers. Correct: low urine output.
5. Previous normal vaccination visit. Does not indicate current dehydration.
6. Unchanged birthmark. Not an acute finding.

Case C — Pediatric dehydration: A 2-year-old with diarrhea and vomiting has poor oral intake, dry mucosa, very few wet diapers and new lethargy. HR 158/min; capillary refill 4 seconds. The clinical team is assessing possible hypovolemia; follow pediatric fluid protocols.

Correct answer: C.

1. The child is adequately hydrated. Perfusion findings contradict this.
2. Uncomplicated hunger alone. Does not explain tachycardia, lethargy and poor refill.
3. Possible moderate-to-severe dehydration with hypovolemia. Correct: fluid losses and poor perfusion require urgent pediatric evaluation.
4. Stable uncomplicated skin rash. Not the main concern.

Case C — Pediatric dehydration: A 2-year-old with diarrhea and vomiting has poor oral intake, dry mucosa, very few wet diapers and new lethargy. HR 158/min; capillary refill 4 seconds. The clinical team is assessing possible hypovolemia; follow pediatric fluid protocols.

Correct answer: D.

1. Long-term sleep training. Lower priority.
2. Routine vaccination review. Not an acute priority.
3. Discharge paperwork. Not before stabilization.
4. Impaired circulation and risk for hypovolemic shock. Correct: perfusion threat takes priority.

Case C — Pediatric dehydration: A 2-year-old with diarrhea and vomiting has poor oral intake, dry mucosa, very few wet diapers and new lethargy. HR 158/min; capillary refill 4 seconds. The clinical team is assessing possible hypovolemia; follow pediatric fluid protocols.

Correct answer: A, B.

1. Urgently assess perfusion and contact the pediatric team. Correct: possible hypovolemia needs prompt evaluation.
2. Prepare for prescribed pediatric rehydration according to clinical protocol. Correct: route and rate depend on severity and orders.
3. Give an unmeasured large fluid bolus without an order or protocol. Unsafe dose and route selection.
4. Wait until the following day. Dangerous delay.
5. Encourage strenuous activity. Unsafe during suspected volume depletion.

Case C — Pediatric dehydration: A 2-year-old with diarrhea and vomiting has poor oral intake, dry mucosa, very few wet diapers and new lethargy. HR 158/min; capillary refill 4 seconds. The clinical team is assessing possible hypovolemia; follow pediatric fluid protocols.

Correct answer: B.

1. Delay care and complete a questionnaire. Unsafe.
2. Assess ABCs and perfusion, activate timely pediatric assistance and implement prescribed rehydration. Correct: coordinated assessment and safe treatment.
3. Give a fixed adult-sized bolus. Unsafe in a young child.
4. Ignore urine output trend. Loses a key perfusion indicator.

Case C — Pediatric dehydration: A 2-year-old with diarrhea and vomiting has poor oral intake, dry mucosa, very few wet diapers and new lethargy. HR 158/min; capillary refill 4 seconds. The clinical team is assessing possible hypovolemia; follow pediatric fluid protocols.

Capillary refill improves to 2 seconds with alert behavior — Improving

• A. Improving: Correct: reassuring perfusion and cognition.
• B. Worsening: Not the observed trend.

Child becomes more lethargic with a weak pulse — Worsening

• A. Improving: Unsafe interpretation.
• B. Worsening: Correct: possible shock.

Urine output improves toward expected age/weight trend — Improving

• A. Improving: Correct: may indicate restored kidney perfusion.
• B. Worsening: Not by itself.

Case D — Community-acquired pneumonia with possible sepsis: A 74-year-old has fever, RR 32/min, SpO₂ 88% despite prescribed oxygen, BP 84/48, HR 126/min, new confusion and low urine output. Emergency assessment and sepsis escalation protocols apply.

Correct answer: B, C, E.

1. Stable old knee scar. Not acute.
2. New confusion. Correct: altered mentation is a red flag.
3. Blood pressure 84/48 mmHg. Correct: marked hypotension.
4. Normal historical glasses prescription. Not relevant.
5. Urine output 10 mL in preceding hour. Correct: possible renal hypoperfusion.
6. Preference for soup. Not urgent.

Case D — Community-acquired pneumonia with possible sepsis: A 74-year-old has fever, RR 32/min, SpO₂ 88% despite prescribed oxygen, BP 84/48, HR 126/min, new confusion and low urine output. Emergency assessment and sepsis escalation protocols apply.

Correct answer: C.

1. Stable age-related fatigue. Does not explain hypotension and organ changes.
2. Uncomplicated upper respiratory infection. Does not account for poor perfusion.
3. Possible sepsis-associated shock with respiratory compromise. Correct: infectious presentation and hypoperfusion demand urgent care.
4. Nonurgent medication refill. Not the emergency.

Case D — Community-acquired pneumonia with possible sepsis: A 74-year-old has fever, RR 32/min, SpO₂ 88% despite prescribed oxygen, BP 84/48, HR 126/min, new confusion and low urine output. Emergency assessment and sepsis escalation protocols apply.

Correct answer: B.

1. Long-term physiotherapy. Later.
2. Immediate airway, breathing and circulation / tissue perfusion. Correct: oxygenation and shock threaten life.
3. Routine discharge education. Not until stabilized.
4. Dietary preferences for next week. Lower priority.

Case D — Community-acquired pneumonia with possible sepsis: A 74-year-old has fever, RR 32/min, SpO₂ 88% despite prescribed oxygen, BP 84/48, HR 126/min, new confusion and low urine output. Emergency assessment and sepsis escalation protocols apply.

Correct answer: A, B.

1. Activate emergency escalation and frequent ABC reassessment. Correct: respond to deterioration immediately.
2. Prepare ordered sepsis investigations, antimicrobial therapy and hemodynamic support. Correct: protocol-directed treatment is time sensitive.
3. Delay provider notification. Unsafe.
4. Encourage ambulation with hypotension. Unsafe.
5. Provide large unprescribed fluid volumes regardless of cardiac status. Fluid therapy must be individualized and ordered.

Case D — Community-acquired pneumonia with possible sepsis: A 74-year-old has fever, RR 32/min, SpO₂ 88% despite prescribed oxygen, BP 84/48, HR 126/min, new confusion and low urine output. Emergency assessment and sepsis escalation protocols apply.

Correct answer: D.

1. Reassess next hour. Unsafe delay.
2. Teach about home medications. Not acute.
3. Arrange routine transport home. Unsafe.
4. Stay with the patient, summon urgent help, support breathing and initiate ordered sepsis resuscitation care. Correct: coordinated emergency response.

Case D — Community-acquired pneumonia with possible sepsis: A 74-year-old has fever, RR 32/min, SpO₂ 88% despite prescribed oxygen, BP 84/48, HR 126/min, new confusion and low urine output. Emergency assessment and sepsis escalation protocols apply.

SpO₂ and work of breathing improve while mental status normalizes — Improving

• A. Improving: Correct: reassuring clinical response.
• B. Worsening: Not the described trend.

Blood pressure falls further with colder extremities — Worsening

• A. Improving: Unsafe interpretation.
• B. Worsening: Correct: perfusion deterioration.

Urine output improves and HR trends down with stable BP — Improving

• A. Improving: Correct: positive perfusion response to keep monitoring.
• B. Worsening: Not by itself.