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NCLEX pharmacology practice questions

20 free NCLEX-style pharmacology questions: high-alert drugs, adverse effects, what to check before giving a dose, antidotes and client teaching, with the answer and the reasoning behind it.

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

At 1500 a nurse on a medical unit reviews four clients with diabetes. Which client should the nurse assess first?

  1. A client who takes metformin, had a glucose of 286 mg/dL at noon and now reports being thirsty
  2. A client who received NPH insulin 16 units and regular insulin 6 units at 0730, ate half of lunch and now says, 'I feel a little shaky'
  3. A client who received insulin glargine 24 units at 2100 last night, skipped lunch because of nausea and had a glucose of 118 mg/dL at noon
  4. A client who received insulin lispro 6 units with a full breakfast at 0800 and now reports feeling tired
Show the answer and rationale

Answer: B

NPH given at 0730 peaks about 4 to 12 hours later, roughly 1130 to 1930, and regular insulin can still be acting at 1500, so a client who ate only half of lunch and now feels shaky is likely becoming hypoglycemic and needs a glucose check and treatment now. Skipping lunch on glargine is the tempting choice, but glargine has no pronounced peak and the last reading was 118 mg/dL. The breakfast lispro lasts about 3 to 5 hours and has worn off, and a glucose of 286 mg/dL with thirst needs follow-up but is not the immediate danger.

📚 Learn it: Insulin Peaks: When the Client Will Crash

Question 2 of 20

A client with heparin-induced thrombocytopenia has received argatroban at 1.5 mcg/kg/min for 10 days. Warfarin was added 6 days ago, after the platelet count recovered. Today the platelet count is 214,000/mm³ and the INR on both drugs is 4.3. The client has no bleeding. Which action should the nurse anticipate?

  1. Stopping the argatroban and rechecking the INR in 4 to 6 hours
  2. Lowering the argatroban rate until the INR falls to 2 to 3, then stopping it
  3. Holding today's warfarin dose because the INR is above the usual goal of 2 to 3
  4. Giving oral vitamin K to bring the INR back into the goal range
Show the answer and rationale

Answer: A

Argatroban raises the INR on its own, so while it overlaps with warfarin the INR reads higher than warfarin alone would produce. At argatroban doses up to 2 mcg/kg/min, the label says to stop it once the combined INR is above 4 and to repeat the INR 4 to 6 hours later; if the INR has then fallen below the desired range, argatroban is restarted and the process is repeated daily. Holding warfarin is the runner-up because 4.3 looks high for warfarin alone, but here it is the expected step toward stopping argatroban. Vitamin K would undo the warfarin, and waiting for a combined INR of 2 to 3 ignores the argatroban effect on the INR.

📚 Learn it: Heparin, Warfarin and the Labs That Rule Them

Question 3 of 20

A nurse reviews the home medications of four clients who have heart failure with reduced ejection fraction (ejection fraction below 40%). Which medication should the nurse clarify with the provider?

  1. Metoprolol succinate 25 mg daily for a client whose apical pulse is 72 beats/min
  2. Amlodipine 5 mg daily for a client whose blood pressure remains 152/90 mm Hg
  3. Apixaban 5 mg twice daily for a client with atrial fibrillation
  4. Verapamil extended-release 180 mg daily for a client with atrial fibrillation
Show the answer and rationale

Answer: D

Nondihydropyridine calcium channel blockers such as verapamil and diltiazem weaken the heart's contraction, and the 2022 AHA/ACC/HFSA heart failure guideline classifies them as harmful in reduced ejection fraction, so the provider needs to choose another rate-control drug. Amlodipine is the runner-up: it is also a calcium channel blocker, but as a dihydropyridine it acts mainly on the arteries and may be used for uncontrolled hypertension in this group. Metoprolol succinate is a recommended beta blocker in reduced ejection fraction and the pulse allows the dose, and apixaban prevents stroke in atrial fibrillation.

📚 Learn it: Digoxin, Beta Blockers and Nitro: Hold Parameters and Hard Stops

Question 4 of 20

A 19-year-old client arrives in the emergency department 5 hours after swallowing about 30 extra-strength acetaminophen tablets. The client is alert, reports mild nausea and says, 'I feel fine, so I guess it didn't do anything.' Which action is the priority?

  1. Give activated charcoal to bind the acetaminophen left in the stomach
  2. Draw a serum acetaminophen level and anticipate acetylcysteine
  3. Draw liver enzymes and start acetylcysteine if they are elevated
  4. Arrange one-to-one observation and a mental health evaluation
Show the answer and rationale

Answer: B

Acetaminophen overdose causes few symptoms for the first 24 hours while the liver is being injured, so the nurse obtains a serum level, which is plotted against the time since ingestion on the treatment nomogram once at least 4 hours have passed, and prepares to give acetylcysteine, which protects the liver best when started within 8 hours. Because this was an intentional overdose, one-to-one observation and a mental health evaluation are needed too, but the time-sensitive threat to the liver comes first. Waiting for liver enzymes to rise loses the antidote window, and a client who feels well is not safe. Activated charcoal may be considered within about 4 hours of an acetaminophen ingestion in an alert client who can protect the airway, so it has little role at 5 hours and never replaces the level and antidote.

📚 Learn it: The Antidote Table You Will See on Exam Day

Question 5 of 20

A nurse is observing a nursing student flush a client's peripherally inserted central catheter (PICC). Which action by the student requires the nurse to intervene?

  1. Using a 10-mL-diameter syringe filled with 5 mL of saline
  2. Flushing with short pushes and pauses instead of one steady push
  3. Using a 3-mL syringe to flush a sluggish catheter
  4. Wearing clean rather than sterile gloves to flush the catheter
Show the answer and rationale

Answer: C

A small-barrel syringe generates far higher pressure, so central catheters are flushed with a 10-mL or larger syringe barrel, and using a 3-mL syringe against resistance can rupture the catheter; resistance is reported, not forced. Clean gloves may look like a lapse, but flushing uses aseptic no-touch technique, not sterile gloves. A 10-mL-diameter syringe keeps pressure low even when partly filled, and a push-pause flush clears the lumen better than a steady push.

📚 Learn it: IV Fluids, Potassium Rules and the First 15 Minutes of a Transfusion

Question 6 of 20 · Select all that apply

A nurse is teaching a client with type 2 diabetes who is starting insulin glargine U-100 once daily with a prefilled pen. Which statements by the client indicate understanding? Select all that apply.

  1. 'I'll keep my spare, unopened pens in the freezer so they last longer.'
  2. 'I'll skip my dose on days my sugar is normal.'
  3. 'Because glargine has no peak, it can't make my sugar go low.'
  4. 'If the insulin in a pen looks cloudy, I won't use it.'
  5. 'I'll inject it at the same time every day.'
  6. 'Once I start a pen, I'll keep it at room temperature and throw it away after 28 days.'
Show the answer and rationale

Answer: D, E, F

Glargine is given once daily at the same time each day, an in-use U-100 pen is kept at room temperature, not refrigerated, and discarded after 28 days, and the solution should be clear and colorless, so a cloudy pen is returned to the pharmacy. The 28-day limit is specific to U-100 glargine pens; the concentrated U-300 pen can be used for up to 56 days once opened. Unopened pens are refrigerated and never frozen. Glargine has no pronounced peak, but hypoglycemia is still its most common adverse reaction, and basal insulin covers the body's background needs, so it is not skipped because a reading is normal.

📚 Learn it: Insulin Peaks: When the Client Will Crash

Question 7 of 20

A client has been receiving IV linezolid for 3 weeks for a bone infection with vancomycin-resistant Enterococcus. Which laboratory result requires the nurse's immediate follow-up?

  1. Serum sodium of 135 mEq/L, down from 138 mEq/L
  2. White blood cell count of 16,200/mm³, up from 14,800/mm³
  3. Platelet count of 62,000/mm³, down from 210,000/mm³
  4. Hemoglobin of 9.9 g/dL, down from 12.1 g/dL at admission
Show the answer and rationale

Answer: C

Linezolid suppresses the bone marrow, especially beyond 2 weeks of therapy, so a platelet count that has crashed from 210,000/mm³ to 62,000/mm³ needs immediate follow-up for bleeding risk and a decision about stopping the drug. The runner-up is the hemoglobin of 9.9 g/dL, part of the same marrow watch, but the fall is slower, it remains above transfusion range, and it does not carry the same acute bleeding risk. A white cell count rising to 16,200/mm³ suggests the infection is not responding and is reviewed with the provider, and a sodium of 135 mEq/L is still normal, although linezolid can cause hyponatremia, so sodium is rechecked.

📚 Learn it: Drug Classes by Suffix and the Side Effect That Defines Each

Question 8 of 20

At 1100 a client with type 1 diabetes is shaky and sweaty with a blood glucose of 58 mg/dL and drinks 4 oz (120 mL) of juice. At 1115 the client is alert, and the glucose is 64 mg/dL. Which action should the nurse take next?

  1. Give a snack with protein, such as cheese and crackers
  2. Recheck the glucose in another 15 minutes
  3. Report the still-low glucose to the provider
  4. Give another 15 g of a fast-acting carbohydrate
Show the answer and rationale

Answer: D

The rule of 15 calls for 15 g of fast-acting carbohydrate, a recheck in 15 minutes, and another 15 g if the glucose is still below 70 mg/dL. This client's 15-minute recheck at 1115 shows 64 mg/dL, so the nurse gives another 15 g and rechecks in 15 minutes; once the glucose is above 70, the client eats a meal or a snack with protein if the next meal is more than an hour away. That snack is the tempting choice, but given now, while the glucose is still low, protein and fat do not raise it quickly. Rechecking without treating leaves the low glucose untreated, and the alert client is treated before the provider is called.

📚 Learn it: Insulin Peaks: When the Client Will Crash

Question 9 of 20

A 78-year-old client with atrial fibrillation takes dabigatran 150 mg twice daily and has a creatinine clearance of 42 mL/min. The client is scheduled for an elective total hip replacement. Which instruction should the nurse expect the prescriber to give about the dabigatran?

  1. Take the last dose on the evening before surgery
  2. Keep taking it, including on the morning of surgery, to prevent a stroke
  3. Take the last dose 3 to 5 days before the surgery
  4. Take the last dose 1 to 2 days before the surgery
Show the answer and rationale

Answer: C

Dabigatran timing before a procedure depends on kidney function: its label calls for stopping it 1 to 2 days ahead when the creatinine clearance is 50 mL/min or more, but 3 to 5 days ahead when it is below 50. The 1-to-2-day window is the runner-up because it is right for normal kidney function, but with a clearance of 42 mL/min the drug lingers and the bleeding risk at surgery stays high. A last dose the evening before, or on the morning of surgery, leaves the full anticoagulant effect in place for a major operation.

📚 Learn it: Heparin, Warfarin and the Labs That Rule Them

Question 10 of 20

A nurse teaches a client with stable angina how to use sublingual nitroglycerin 0.4 mg tablets, following current American Heart Association guidance. Which statement by the client indicates that the teaching was effective?

  1. 'I'll take up to three tablets 5 minutes apart and call 911 if the third one doesn't help.'
  2. 'I'll keep a few tablets in my weekly pill organizer so they're always with me.'
  3. 'If my chest pain isn't better 5 minutes after the first tablet, I'll call 911.'
  4. 'I'll swallow a tablet with water as soon as the pain starts.'
Show the answer and rationale

Answer: C

Current teaching based on AHA guidance is to sit down, let one tablet dissolve under the tongue, and call 911 if the pain is not better or is worse 5 minutes later, because a heart attack may be under way. Three tablets before calling is the runner-up: it was the standard teaching and matches the 'every 5 minutes, up to 3 doses' wording of many prescriptions, but it delays emergency care by 10 minutes or more. Nitroglycerin breaks down with heat and light, so it stays in its original airtight glass bottle, and the tablet is dissolved under the tongue, never swallowed.

📚 Learn it: Digoxin, Beta Blockers and Nitro: Hold Parameters and Hard Stops

Practice 10 more Pharmacology 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 is reviewing pain prescriptions for four clients. Which prescription should the nurse question?

  1. Fentanyl 25 mcg/hr patch for an opioid-naive client after knee surgery
  2. Morphine PCA without a basal rate after an open hysterectomy today
  3. Oral oxycodone 5 mg every 4 hours as needed for an opioid-naive adult
  4. Gabapentin 300 mg at bedtime for diabetic peripheral neuropathy
Show the answer and rationale

Answer: A

Transdermal fentanyl is only for opioid-tolerant clients with severe, persistent pain; it takes 12 to 24 hours to reach effective blood levels and keeps releasing drug after removal, so in an opioid-naive client with acute postoperative pain it can cause fatal respiratory depression, and its label contraindicates both uses. A morphine PCA may look riskier, but it is appropriate after major surgery, and leaving out a basal rate follows current guidance for opioid-naive adults. Oral oxycodone 5 mg as needed is a usual starting dose for an opioid-naive adult, and gabapentin treats neuropathic pain.

📚 Learn it: The Antidote Table You Will See on Exam Day

Question 12 of 20

A nurse is caring for a client who has an arteriovenous fistula in the left forearm for hemodialysis and needs a peripheral IV and admission laboratory tests. Which action by the nurse is appropriate?

  1. Request a PICC line in the right arm for labs
  2. Start the IV in the right forearm cephalic vein
  3. Insert the IV in a hand vein of the left arm
  4. Insert the IV catheter in a vein of the right hand
Show the answer and rationale

Answer: D

An arteriovenous fistula must be protected from compression and puncture to prevent clotting, infection, and loss of the client's dialysis access, so IV insertion, blood pressure measurement, tourniquets, and venipuncture are all done on the other arm, and only trained dialysis staff access the fistula. A hand vein on the non-fistula side is preferred because it spares the arm veins that may be needed for future dialysis access. The right forearm cephalic vein is on the correct side but is one of the veins most often used for a future fistula. A left hand vein is still in the access arm, and a PICC line damages veins that future access depends on.

📚 Learn it: IV Fluids, Potassium Rules and the First 15 Minutes of a Transfusion

Question 13 of 20

A 39-year-old client with rheumatoid arthritis who injects adalimumab every 2 weeks is planning a trip to South America and asks about vaccines. Which vaccine should the nurse tell the client to avoid while taking adalimumab?

  1. Hepatitis A vaccine
  2. Recombinant zoster (shingles) vaccine
  3. Yellow fever vaccine
  4. Injectable typhoid vaccine
Show the answer and rationale

Answer: C

Adalimumab is a tumor necrosis factor blocker that weakens the immune response, and a live vaccine such as yellow fever can cause the very infection it is meant to prevent in an immunosuppressed client, so live vaccines are avoided during treatment. The recombinant zoster vaccine sounds risky because an older shingles vaccine was live, but the current one contains no live virus and is recommended for adults with weakened immune systems. The injectable typhoid vaccine is inactivated, unlike the oral typhoid vaccine, which is live, and the hepatitis A vaccine is inactivated too, so both can be given.

📚 Learn it: Drug Classes by Suffix and the Side Effect That Defines Each

Question 14 of 20 · Select all that apply

A nurse is teaching a client with atrial fibrillation and normal kidney function who is starting rivaroxaban 20 mg once daily. Which statements by the client indicate understanding? Select all that apply.

  1. 'If I ever start bleeding, a shot of vitamin K will reverse it.'
  2. 'I'll take it with my evening meal.'
  3. 'I'll tell my dentist and surgeon that I take it, since it's usually stopped at least a day before a procedure.'
  4. 'I'll take it first thing in the morning on an empty stomach so it absorbs better.'
  5. 'If I can't swallow the tablet, I can crush it into applesauce and then eat a meal right away.'
Show the answer and rationale

Answer: B, C, E

The label directs that rivaroxaban 20 mg for atrial fibrillation be taken with the evening meal, and a crushed 15 or 20 mg tablet may be mixed with applesauce as long as food follows right away. It is usually stopped at least 24 hours before a procedure, so every dentist and surgeon needs to know about it. An empty stomach is the tempting choice because many drugs are taken that way, but the 15 and 20 mg doses are meant to be taken with food. The label states that vitamin K, like protamine, is not expected to reverse rivaroxaban.

📚 Learn it: Heparin, Warfarin and the Labs That Rule Them

Question 15 of 20

A client with type 2 diabetes takes NPH insulin 12 units with regular insulin 4 units before breakfast and NPH insulin 14 units before the evening meal at 1700. For 3 nights the client has woken at about 0300 sweaty and shaky with readings of 54 to 62 mg/dL and has treated each low with juice and crackers. The 0700 readings have been 196 to 228 mg/dL. Which change should the nurse anticipate?

  1. Lowering the evening dose of NPH insulin
  2. Moving the morning regular insulin to after breakfast
  3. Raising the evening NPH dose to bring down the morning readings
  4. Adding regular insulin at bedtime
Show the answer and rationale

Answer: A

NPH given at 1700 peaks about 4 to 12 hours later, from about 2100 to 0500, so the 0300 lows come from the evening NPH, and the ADA advises changing the regimen after a low to prevent further hypoglycemia. Raising the evening NPH is the runner-up because the morning numbers are high, but they follow overnight lows treated with juice and crackers, and more NPH would deepen the 0300 lows. Bedtime regular insulin adds insulin at the riskiest time, and moving the morning regular dose does not affect the night.

📚 Learn it: Insulin Peaks: When the Client Will Crash

Question 16 of 20

A 72-year-old client with atrial fibrillation who has taken warfarin for 3 years is being switched to apixaban 5 mg twice daily because the INR has been hard to keep in range. The last warfarin dose was taken last evening, and this morning's INR is 2.6. When should the nurse expect the first dose of apixaban to be given?

  1. When a repeat INR is below 2.0, with no more warfarin given before then
  2. Tonight, along with one last dose of warfarin, so that the two drugs overlap
  3. Now, since the warfarin has been stopped and protection is needed
  4. After a dose of oral vitamin K has brought the INR down to normal
Show the answer and rationale

Answer: A

The apixaban label says to stop warfarin and start apixaban once the INR is below 2.0, so the first dose waits for a repeat INR under that level. Overlapping the drugs is the runner-up because it sounds like the familiar heparin-to-warfarin bridge, but here it only stacks two anticoagulants and raises the bleeding risk, and giving apixaban now with an INR of 2.6 does the same. Vitamin K is not needed for the switch; the INR drifts down on its own once warfarin stops.

📚 Learn it: Heparin, Warfarin and the Labs That Rule Them

Question 17 of 20

A 79-year-old client has taken losartan 100 mg, hydrochlorothiazide 25 mg and atorvastatin 20 mg daily for 4 years with stable kidney function. She comes to the clinic tired, saying she has been urinating much less. Ten days ago she began taking naproxen 500 mg twice daily for knee pain. Her creatinine is 2.2 mg/dL, up from 1.0 mg/dL 3 months ago, and her potassium is 5.3 mEq/L. Which medication most likely triggered these changes?

  1. Hydrochlorothiazide
  2. Losartan
  3. Naproxen
  4. Atorvastatin
Show the answer and rationale

Answer: C

The only recent change is naproxen. NSAIDs constrict the afferent arteriole that feeds the glomerulus, and the losartan label warns that adding an NSAID to an angiotensin receptor blocker in a client who is older or volume-depleted, including from a diuretic, can cause acute kidney injury. Losartan is the runner-up because it can raise creatinine and potassium, but it caused no problem for 4 years until the NSAID was added. The thiazide adds volume loss but has also been stable, and atorvastatin can rarely injure the kidneys through muscle breakdown, but she has no muscle pain and has taken it for years.

📚 Learn it: Digoxin, Beta Blockers and Nitro: Hold Parameters and Hard Stops

Question 18 of 20

A 79-year-old client with heart failure received digoxin immune Fab 2 hours ago for digoxin toxicity, with a heart rate of 38 beats/min and a serum potassium of 6.1 mEq/L before treatment. Which finding now requires immediate follow-up?

  1. A serum digoxin level higher than the one drawn before treatment
  2. A heart rate of 72 beats/min, up from 38 beats/min
  3. Nausea that has eased, and the client asks for crackers
  4. A serum potassium of 2.9 mEq/L
Show the answer and rationale

Answer: D

Serum potassium can fall rapidly after digoxin immune Fab, especially in the first several hours, so a level of 2.9 mEq/L is reported at once for cautious replacement; a low potassium brings its own risk of dysrhythmias. The higher digoxin level is the runner-up, but after Fab the total serum digoxin can rise sharply because the assay counts digoxin bound to the Fab, which cannot act, so standard levels are misleading. A heart rate back to 72 and easing nausea show the toxicity resolving.

📚 Learn it: The Antidote Table You Will See on Exam Day

Question 19 of 20

A 66-year-old client is 1 day after a bowel resection, with a nasogastric tube to suction. The morning potassium is 3.1 mEq/L, and the provider prescribes potassium chloride 20 mEq in 1,000 mL of 0.45% sodium chloride at 100 mL/hr. The urine output has been 15 to 20 mL/hr for 4 hours, and the creatinine is 1.9 mg/dL, up from 0.9 mg/dL yesterday. What should the nurse do?

  1. Start the infusion, because 2 mEq/hr is well under the peripheral limit
  2. Start the infusion and recheck the potassium level in 4 hours
  3. Run the infusion at 50 mL/hr until the urine output improves
  4. Hold the potassium-containing fluid and report the urine output and creatinine
Show the answer and rationale

Answer: D

Potassium is cleared by the kidneys, and the labeling for potassium-containing IV fluids warns that reduced kidney function can cause potassium to build up; standard practice is to confirm adequate urine output, at least 30 mL/hr (0.5 mL/kg/hr), before giving IV potassium. Fifteen to 20 mL/hr of urine with a creatinine that has doubled signals acute kidney injury, so the potassium could rise to dangerous levels; the nurse holds the fluid and reports, and the provider can order a potassium-free fluid if the client is dry. The runner-up is right that 2 mEq/hr is a safe rate, but rate does not matter when the kidneys cannot excrete potassium. Starting and rechecking later accepts that risk, and halving the rate is an unprescribed change that still gives potassium.

📚 Learn it: IV Fluids, Potassium Rules and the First 15 Minutes of a Transfusion

Question 20 of 20

A 45-year-old client with Crohn disease is scheduled for a first infusion of infliximab today. An interferon-gamma release assay drawn last week is positive, the chest x-ray is clear, and the client has no cough, fever or night sweats. Which action should the nurse take?

  1. Give the infusion, since the clear chest x-ray rules out tuberculosis
  2. Premedicate with acetaminophen and diphenhydramine, then start the infusion
  3. Hold the infusion and report the test result to the provider right away
  4. Give the infusion and plan to repeat the chest x-ray in 6 months
Show the answer and rationale

Answer: C

A positive interferon-gamma release assay with a clear chest x-ray and no symptoms means latent tuberculosis infection, and tumor necrosis factor blockers such as infliximab carry a boxed warning that latent TB can reactivate, so treatment for latent TB begins before the first dose. A clear x-ray rules out active disease, not latent infection. Premedication may be used to lessen infusion reactions, but it does nothing about the TB risk, and a repeat x-ray in 6 months would only detect reactivation that treatment could have prevented.

📚 Learn it: Drug Classes by Suffix and the Side Effect That Defines Each

Practice 10 more Pharmacology questions free →

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