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NCLEX med-surg practice questions

20 free NCLEX-style medical-surgical questions: cardiac, respiratory, renal, endocrine and neuro care, complications to catch early and what to do first, with rationales.

Tap an answer to check it, or open "Show the answer and rationale" under each question. Every client is fictional. For exam practice only, not medical advice.

Question 1 of 20

A client with acute kidney injury has a potassium of 7.0 mEq/L, and the cardiac monitor shows a widened QRS. The nurse gives calcium gluconate 10 mL of 10% solution IV over 3 minutes as prescribed, and 5 minutes later the QRS has narrowed. Which prescription should the nurse carry out next?

  1. Sodium zirconium cyclosilicate 10 g by mouth
  2. Regular insulin 10 units IV with 25 g of dextrose
  3. A repeat potassium level to see whether it has fallen
  4. Furosemide 40 mg IV push
Show the answer and rationale

Answer: B

Calcium stabilizes the heart's cell membranes within minutes, but it does not lower the potassium and its effect lasts only 30 to 60 minutes. The next step is to shift potassium into the cells with IV insulin and dextrose, the fastest way to lower the serum level. Sodium zirconium cyclosilicate is the runner-up: it removes potassium through the gut, but it takes about an hour to start working and does not replace the shift. A level drawn now would still be high, because calcium does not change it, and furosemide acts slowly and only if the injured kidneys make urine.

📚 Learn it: Potassium: The Electrolyte That Stops Hearts

Question 2 of 20

A client with small cell lung cancer says that shirt collars have started to feel tight and the face looks puffy, especially in the morning. The nurse notes swelling of the face, neck, and both arms, distended veins across the upper chest, and shortness of breath when the client lies flat. Which action should the nurse take?

  1. Apply cool compresses to the face and neck to ease swelling
  2. Check the blood pressure in each arm and report the readings
  3. Raise the head of the bed and notify the provider
  4. Raise the arms on pillows to drain the swelling
Show the answer and rationale

Answer: C

Swelling of the face, neck, and arms with distended chest wall veins and breathlessness when lying flat suggests superior vena cava syndrome, in which a tumor compresses the vein that drains the upper body; raising the head of the bed eases breathing and venous drainage while the provider is notified, because airway swelling or cerebral edema can develop. Checking the blood pressure in each arm sounds like a thorough assessment, but blood pressure cuffs are kept off the arms, where venous return is obstructed, and it delays the positioning that eases breathing. Raising the arms does not relieve a blockage in the central vein, and cool compresses are a comfort measure that does nothing for the obstruction or the breathing.

📚 Learn it: Burns: The Parkland Formula and Neutropenic Fever

Question 3 of 20

A nurse on an endocrine unit receives a handoff report on four clients. Which client should the nurse assess first?

  1. A client with diabetes insipidus whose serum sodium is 147 mEq/L
  2. A client with Cushing's syndrome who has a fasting glucose of 168 mg/dL
  3. A client with SIADH whose sodium fell from 128 to 119 mEq/L overnight
  4. A client with hyperthyroidism whose resting heart rate is 112 beats/min
Show the answer and rationale

Answer: C

A rapid fall in sodium to 119 mEq/L draws water into brain cells and can cause confusion, seizures, and herniation, so the client with SIADH is the most unstable. A sodium of 147 mEq/L in diabetes insipidus is also abnormal, which makes it tempting, but it is only mildly high and fits the water loss of the disease rather than a sudden change. Hyperglycemia is an expected effect of excess cortisol in Cushing's syndrome, and a resting heart rate of 112 is a common, stable finding in hyperthyroidism that can wait.

📚 Learn it: Sodium, Calcium and Magnesium: Twitching, Seizing and Going Flat

Question 4 of 20

A nurse reviews arterial blood gas results for four clients. Which client requires the nurse's immediate action?

  1. A client who was given IV morphine 2 hours ago: pH 7.24, PaCO2 62 mm Hg, HCO3 26 mEq/L
  2. A client with 3 days of watery diarrhea: pH 7.34, PaCO2 31 mm Hg, HCO3 16 mEq/L
  3. A client anxious before surgery: pH 7.48, PaCO2 32 mm Hg, HCO3 23 mEq/L
  4. A client with long-standing COPD on home oxygen: pH 7.35, PaCO2 66 mm Hg, HCO3 35 mEq/L
Show the answer and rationale

Answer: A

The client given morphine has an acute respiratory acidosis: the pH is low and the PaCO2 high, but the bicarbonate is still normal because the kidneys need days to compensate. Hypoventilation from the opioid is happening now and calls for stimulation, airway support, and naloxone as prescribed. The COPD result is the runner-up because its PaCO2 is even higher, but the raised bicarbonate and normal pH show a chronic, compensated state. The diarrhea result is a mild, partially compensated metabolic acidosis and the anxiety result a mild respiratory alkalosis; both need attention but are not immediate threats.

📚 Learn it: ABGs in Three Steps: ROME

Question 5 of 20

A client with hyperosmolar hyperglycemic state has received 3 L of 0.9% sodium chloride, and an insulin infusion at 0.05 units/kg/hr was started at 1000. Hourly glucose results: 0900, 1,080 mg/dL; 1000, 1,010 mg/dL; 1100, 840 mg/dL; 1200, 650 mg/dL. The client is drowsy but arousable. Which action should the nurse take?

  1. Stop the IV fluids and keep the insulin running
  2. Continue the infusion, since the glucose is still above 600
  3. Report how fast the glucose is falling to the provider
  4. Add 5% dextrose to the IV fluid now
Show the answer and rationale

Answer: C

In HHS the glucose should fall no faster than about 90 to 120 mg/dL per hour, because a rapid fall drops the serum osmolality quickly and can shift water into brain cells. This client's glucose fell 170 and then 190 mg/dL in an hour, so the nurse reports it for a lower insulin rate and keeps checking the level of consciousness. Continuing because the value is still high is the tempting runner-up, but the speed of change matters, not just the number. Dextrose is added once the glucose falls below 250 mg/dL, and stopping fluids in a client with a large water deficit would worsen the dehydration.

📚 Learn it: DKA Versus HHS: Ketones, Fluids and the Potassium Trap

Question 6 of 20 · Select all that apply

A nurse reviews the records of clients on a medical unit. Which clients should the nurse identify as being at increased risk for hyperkalemia? Select all that apply.

  1. An 80-year-old with chronic kidney disease who takes lisinopril and just started trimethoprim-sulfamethoxazole
  2. A client with asthma receiving frequent nebulized albuterol treatments
  3. A client with untreated primary adrenal insufficiency (Addison's disease)
  4. A client found on the floor after 2 days with crush injuries of both legs and dark brown urine
  5. A client with DKA who has been receiving an insulin infusion for 6 hours
  6. A client with heart failure who started IV furosemide twice daily
Show the answer and rationale

Answer: A, C, D

Trimethoprim blocks sodium channels in the collecting duct much as amiloride does, so added to an ACE inhibitor in an older adult with kidney disease it can raise potassium quickly. Crushed muscle releases potassium as cells break down, and dark urine signals myoglobin that can injure the kidneys and stop excretion. Without aldosterone, the kidneys in Addison's disease retain potassium. DKA raises potassium at presentation, which makes it tempting, but after 6 hours of insulin potassium is moving into cells and falling. Furosemide wastes potassium in the urine, and albuterol shifts it into cells, which is why it is used to treat hyperkalemia.

📚 Learn it: Potassium: The Electrolyte That Stops Hearts

Question 7 of 20

A 70-year-old client with heart failure with reduced ejection fraction is admitted with worsening breathlessness. Blood pressure 84/68 mm Hg, heart rate 112 beats/min, crackles in both lungs, distended neck veins, cool and mottled legs, new confusion, and a urine output of 15 mL/hr. Which prescription should the nurse question?

  1. Nitroglycerin infusion to reduce preload
  2. Hold tonight's scheduled dose of carvedilol
  3. Furosemide 40 mg IV now
  4. Dobutamine infusion titrated to perfusion
Show the answer and rationale

Answer: A

Cool, mottled legs, confusion, scant urine, and a narrow pulse pressure show that too little blood is reaching the organs, while crackles and distended neck veins show congestion, a 'cold and wet' picture that can slide into cardiogenic shock. Nitroglycerin lowers the pressure further and should be clarified when the systolic pressure is below 90 mm Hg. Holding carvedilol is the runner-up to question, since beta blockers are core heart failure therapy, but they weaken contraction and are held while the client is hypotensive with poor perfusion. Dobutamine supports contraction, and IV furosemide treats the congestion.

📚 Learn it: MI and Heart Failure: Minutes and Pounds

Question 8 of 20

A client had a left carotid endarterectomy 4 hours ago. Which finding requires immediate action by the nurse?

  1. Incisional pain rated 3 on a 0-to-10 scale
  2. Weak right hand grip that was strong 1 hour ago
  3. Heart rate of 56 beats/min, and the client denies dizziness
  4. Numbness of the left earlobe and the skin near the incision
Show the answer and rationale

Answer: B

Surgery on the left carotid artery can release emboli or reduce flow to the left hemisphere, which controls the right side of the body, so new weakness of the right hand is a stroke until proven otherwise and must be reported at once. Numbness of the left earlobe and the skin near the incision sounds neurologic, but it comes from small sensory nerves cut or stretched during surgery on the operative side and usually fades. A heart rate of 56 without dizziness is a common effect of carotid sinus stimulation after surgery and is monitored, and mild incisional pain is expected. The nurse would also act immediately on neck swelling or difficulty breathing, because a hematoma can compress the airway.

📚 Learn it: Stroke Windows and Rising Intracranial Pressure

Question 9 of 20

A client is returning to the unit after a tracheostomy was placed this morning. Which item is most important for the nurse to have at the bedside?

  1. A humidified oxygen source with a tracheostomy collar fitted for the client
  2. Spare tracheostomy tubes, same size and one size smaller, and an obturator
  3. A bag-valve mask with oxygen tubing, checked and ready at the head of the bed
  4. A working suction unit with sterile catheters and a Yankauer tip within reach
Show the answer and rationale

Answer: B

A tracheostomy placed this morning has an immature tract that can narrow and close within minutes if the tube comes out, so spare tubes of the same size and one size smaller plus an obturator stay at the bedside for emergency reinsertion. The runner-up is the working suction unit, because suction is essential for a client who cannot clear secretions, but suction equipment does not solve a lost airway from a displaced tube. A bag-valve mask with oxygen is valuable backup ventilation, yet reinserting the tube restores the secure airway. Humidified oxygen with a tracheostomy collar supports oxygenation and keeps secretions moist once the tube is confirmed in place.

📚 Learn it: Chest Tubes, COPD and the Silent Chest

Question 10 of 20

A nurse is screening four clients on a medical unit for sepsis. Which client's findings most strongly suggest sepsis?

  1. A 67-year-old on day 3 after a colectomy with a temperature of 95.9°F (35.5°C), RR 26, and new confusion
  2. A 70-year-old with heart failure, RR 24, ankle edema, and crackles after missed furosemide doses
  3. A 34-year-old with a temperature of 100.4°F (38°C) and muscle aches the day after a flu vaccine
  4. A 58-year-old 1 day after surgery with a temperature of 99.9°F (37.7°C), HR 94, and incisional pain
Show the answer and rationale

Answer: A

Sepsis can lower the temperature as well as raise it, so a temperature below 96.8°F (36°C) with a rapid respiratory rate and new confusion on day 3 after bowel surgery, when wound and anastomotic infections tend to appear, meets sepsis screening criteria and needs evaluation now; waiting for a fever would delay treatment. The client 1 day after surgery has a mild temperature rise and a heart rate of 94, which fit the normal inflammatory response and pain of the first day, with no sign of organ dysfunction. Tachypnea with crackles and edema after missed furosemide points to fluid overload, and a low-grade fever with aches the day after a vaccine is an expected reaction.

📚 Learn it: Four Kinds of Shock and the First Hour of Sepsis

Practice 10 more Med-surg questions free →

A timed or tutor-mode set in the app, scored by area, with every miss saved for review. Free, no sign-up needed.

Question 11 of 20

A nurse on a surgical unit receives a report on four clients. Which client should the nurse see first?

  1. A client 6 hours after a total thyroidectomy who reports tingling around the mouth and in the fingertips
  2. A client with Hashimoto's thyroiditis who started levothyroxine 3 days ago and says she still feels tired and cold all day
  3. A client taking methimazole for Graves' disease who reports a mild, itchy rash on both forearms
  4. A client with Graves' disease, 1 day after an appendectomy, with a temperature of 103.6°F (39.8°C), a pulse of 148, and new confusion
Show the answer and rationale

Answer: D

High fever, a pulse of 148, and new confusion in a client with Graves' disease after surgery, a common trigger, signal thyroid storm, a crisis in which the heart and brain can fail within hours. Tingling around the mouth and fingertips after thyroidectomy is the runner-up and needs a prompt calcium check, because it is an early sign of hypocalcemia from parathyroid injury, but it is an early warning, while the storm is already causing organ dysfunction. Fatigue 3 days into levothyroxine is expected, because the effect builds over weeks, and a mild rash is a common, minor side effect of methimazole, unlike fever or a sore throat.

📚 Learn it: Thyroid, Adrenal and the Water Hormones

Question 12 of 20

A client with type 2 diabetes and heart failure is seen in the preadmission clinic 1 week before an elective total knee replacement. Home medications are metformin, dapagliflozin, metoprolol succinate, and atorvastatin. Which instruction should the nurse expect the provider to give?

  1. Stop metformin at least 3 days before the surgery
  2. Skip the morning metoprolol on the day of surgery
  3. Stop the atorvastatin 1 week before the day of surgery
  4. Stop dapagliflozin at least 3 days before surgery
Show the answer and rationale

Answer: D

SGLT2 inhibitors such as dapagliflozin can cause ketoacidosis, sometimes with a near-normal glucose, when a client fasts and goes through the stress of surgery, so FDA labeling calls for stopping dapagliflozin, canagliflozin, and empagliflozin at least 3 days before scheduled surgery (ertugliflozin at least 4). Metformin is the runner-up because it is also held, but only on the day of surgery, not days ahead. Beta blockers such as metoprolol are continued, including the morning of surgery with a sip of water, because stopping them suddenly can cause rebound tachycardia and ischemia, and statins are continued as well.

📚 Learn it: The Pre-op Checklist: NPO, Consent, Jewelry, Void

Question 13 of 20

This morning, a client on the second day after an open cholecystectomy had a temperature of 100.8°F (38.2°C), diminished breath sounds in both bases, and an SpO2 of 91% on room air. The nurse coached incentive spirometry and helped the client walk. Which finding this afternoon best indicates that the interventions were effective?

  1. The client rates incisional pain 2 on a 0-to-10 scale
  2. Temperature is 99.0°F (37.2°C) an hour after the scheduled acetaminophen
  3. The client reached 1,000 mL on the spirometer once during the morning
  4. The lungs sound clear throughout, and oximetry is 96% without oxygen
Show the answer and rationale

Answer: D

Atelectasis is the collapse of alveoli in the lung bases, so lungs that sound clear throughout, with a saturation back to 96% without oxygen, show that the alveoli have reopened. A lower temperature is the runner-up because fever was part of the picture, but a reading taken an hour after acetaminophen reflects the drug, not the lungs. Reaching a good volume once shows the client can use the device, not that the lungs have re-expanded, which takes repeated use about 10 times an hour while awake. Less pain makes deep breathing easier but is not itself a lung outcome.

📚 Learn it: Post-op Days 1 Through 10: What Goes Wrong When

Question 14 of 20 · Select all that apply

A nurse finds a client on a telemetry unit unresponsive, not breathing, and without a pulse. The monitor shows ventricular fibrillation, and the code team arrives with the defibrillator. Which actions are appropriate during the resuscitation? Select all that apply.

  1. Pause compressions every minute to check for a pulse
  2. Compress at least 2 inches (5 cm) deep and allow full recoil
  3. Give atropine 1 mg IV every 3 to 5 minutes
  4. Compress the chest at a rate of 100 to 120 per minute
  5. Resume compressions immediately after each shock
  6. Use the synchronized mode so the shock lands on the R wave
Show the answer and rationale

Answer: B, D, E

High-quality CPR means compressions at 100 to 120 per minute, at least 2 inches (5 cm) deep, with full chest recoil and few pauses, and compressions resume right after each shock for 2 minutes before the rhythm is checked again, because the heart rarely pumps well in the first moments after defibrillation. Synchronizing is the tempting wrong choice, but ventricular fibrillation has no R wave to time to, so the shock may never fire; it is delivered unsynchronized. Pulse checks happen only at the 2-minute rhythm checks, and atropine is not part of the arrest algorithm, in which epinephrine 1 mg every 3 to 5 minutes is the drug given.

📚 Learn it: MI and Heart Failure: Minutes and Pounds

Question 15 of 20

A client who received midazolam and fentanyl for a same-day upper endoscopy is being evaluated for discharge. Which finding indicates the client is not yet ready to go home?

  1. The client reports a mildly sore throat when swallowing
  2. The client falls back asleep between the nurse's questions
  3. The client has mild bloating and cramps and is passing gas
  4. Blood pressure is 104/66 mm Hg, down from 118/72 before
Show the answer and rationale

Answer: B

Discharge after moderate sedation requires a return to the baseline level of consciousness, so a client who keeps drifting back to sleep is still under the effects of midazolam and fentanyl and needs continued monitoring. A blood pressure of 104/66 looks low, but it is within 20% of the preprocedure 118/72, a common discharge criterion. Mild bloating and cramps from air introduced during the procedure are expected and ease as the client passes gas, and a mildly sore throat after an endoscope is expected. Even once the client meets the criteria, a responsible adult must drive the client home.

📚 Learn it: Procedure Prep and Aftercare: The Questions You Will Get

Question 16 of 20

Thirty-six hours after a femur fracture, a client becomes restless and confused, with a respiratory rate of 32 breaths/min, an oxygen saturation of 86%, and petechiae across the chest. Which action should the nurse take first?

  1. Give the PRN anxiolytic for the agitation
  2. Call the rapid response team to assess the client
  3. Raise the head of the bed to high Fowler's position
  4. Apply high-concentration oxygen by non-rebreather
Show the answer and rationale

Answer: D

Restlessness, hypoxemia, tachypnea, and chest petechiae a day or two after a long-bone fracture describe fat embolism syndrome, and the first priority is oxygenation with high-concentration oxygen. Calling the rapid response team is the right next step and sounds first, but the nurse can start treating a saturation of 86% at once and summon the team right after. Raising the head of the bed eases breathing but cannot correct this degree of hypoxemia by itself, and the confusion is a sign of hypoxia, so sedating it hides the problem and depresses breathing.

📚 Learn it: Compartment Syndrome and Fat Embolism: Pain and Petechiae

Question 17 of 20

A nurse observes assistive personnel (AP) applying sequential compression devices to a client on the first day after abdominal surgery. Which action by the AP requires the nurse to intervene?

  1. Taking the sleeves off before the client walks to the bathroom and back to bed
  2. Wrapping the sleeve around a calf that is swollen, warm and tender
  3. Putting the sleeves back on within an hour after the client walked in the hallway
  4. Fitting the sleeve loosely enough at the top to slip two fingers underneath
Show the answer and rationale

Answer: B

A swollen, warm, tender calf may hold a deep vein thrombosis, and compressing that leg could dislodge a clot and send it to the lungs, so the sleeve stays off that leg while the nurse assesses the client and notifies the provider. Putting the sleeves back on within an hour after the client walked in the hallway is the runner-up because walking can seem protective enough on its own, but compression is still needed whenever the client is in bed or seated. Fitting the sleeve loosely enough at the top to slip two fingers underneath prevents constriction, and taking the sleeves off before the client walks to the bathroom and back to bed is expected because the devices are worn while the client is not ambulating.

📚 Learn it: DVT Prevention and the Pulmonary Embolism You Must Not Miss

Question 18 of 20

A 64-year-old client with metastatic lung cancer has a large pericardial effusion and is scheduled for pericardiocentesis in 1 hour. BP is 90/72 mm Hg and heart rate 122 beats/min, the neck veins are distended with the head of the bed at 45 degrees, and the heart sounds are muffled. The lungs are clear. Which prescription should the nurse question?

  1. Norepinephrine infusion titrated to keep the mean arterial pressure at 65 mm Hg or higher
  2. Bedside echocardiogram just before the procedure to guide the needle placement
  3. Furosemide 40 mg IV now
  4. 0.9% sodium chloride 500 mL IV over 15 minutes
Show the answer and rationale

Answer: C

In tamponade, pericardial fluid squeezes the heart, so the ventricles fill only while venous pressure stays high enough to push blood in; a diuretic lowers that pressure and can make cardiac output collapse, so the nurse questions furosemide even though the neck veins are distended. The fluid bolus is the runner-up because it seems wrong with distended neck veins, but added volume can briefly support filling and blood pressure until the effusion is drained. A norepinephrine infusion titrated to a mean arterial pressure of 65 mm Hg or higher is an appropriate bridge that supports perfusion without reducing preload. A bedside echocardiogram to guide needle placement is standard for pericardiocentesis and improves its safety.

📚 Learn it: Tamponade, Tension Pneumothorax and Autonomic Dysreflexia

Question 19 of 20

A client admitted with alcohol use disorder has received 120 mEq of potassium chloride over 2 days, but the potassium remains 3.0 mEq/L. Which laboratory result should the nurse review next?

  1. Arterial pH
  2. Serum magnesium
  3. Serum glucose
  4. Serum calcium
Show the answer and rationale

Answer: B

The kidneys need magnesium to hold on to potassium, so when magnesium is low, as it often is with heavy alcohol use, potassium keeps leaking into the urine and will not rise no matter how much is given; magnesium is replaced first or along with the potassium. Low magnesium and low potassium together also raise the risk of dysrhythmias. Arterial pH is the closest distractor: alkalosis shifts potassium into cells, but low magnesium is the classic cause of potassium that will not correct in heavy drinkers. Calcium often falls with magnesium but does not govern potassium handling, and nothing in this client's picture points to high glucose, which raises urine potassium losses only through an osmotic diuresis.

📚 Learn it: Potassium: The Electrolyte That Stops Hearts

Question 20 of 20

A client who weighs 154 lb (70 kg) has partial- and full-thickness burns over 45% of the total body surface area. The burn occurred at 0100, and the first 8 hours of lactated Ringer's were given on schedule. Using the Parkland formula (4 mL/kg/%TBSA), what hourly rate does the formula give for the remaining 16 hours? Round to the nearest whole number.

  1. 788 mL/hr
  2. 525 mL/hr
  3. 197 mL/hr
  4. 394 mL/hr
Show the answer and rationale

Answer: D

The Parkland total is 4 mL × 70 kg × 45% = 12,600 mL for the first 24 hours after the burn. Half, 6,300 mL, is given in the first 8 hours (0100 to 0900), and the other 6,300 mL over the next 16 hours: 6,300 ÷ 16 = 393.75, or 394 mL/hr. Keeping the first-8-hour rate (6,300 ÷ 8 = 788 mL/hr) is the most common error, and 525 mL/hr spreads the total evenly over 24 hours. 197 mL/hr comes from using 2 mL/kg/%TBSA instead of the 4 mL in the order. The calculated rate is only a starting point that is then adjusted to the urine output.

📚 Learn it: Burns: The Parkland Formula and Neutropenic Fever

Practice 10 more Med-surg questions free →

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