Nursing school graduates must successfully pass the NCLEX-RN to legally practice as a registered nurse. Such a crucial exam is, understandably, anxiety-inducing for those who must endure it, but resources abound to help nursing school graduates prepare for it.
Each version of the NCLEX-RN is cultivated using a detailed test plan that is released to the public to aid in preparing for boards. Read on to find a breakdown of the information you will likely see on the NCLEX-RN to guide your study as well as sample questions to test your current knowledge.
The NCLEX-RN is a computer-adaptive test based on a “passing standard.” This passing standard helps the National Council of State Boards of Nursing (NCSBN) determine the graduate nurses who have the necessary knowledge to practice at (or above) a minimum competency level.
The test asks the question, “What is the minimum amount a novice nurse must know in order to safely practice at a beginning level of nursing?” Think of the passing standard as the ground floor of a building. Correctly answering a question at the ground floor prompts the next question to be above the passing standard. If you answer the more difficult question correctly as well, a more complicated question comes next. You move up a floor with each correct answer.
This trend continues until you get a question wrong, which drops the next question closer to the passing standard. Once the test algorithm has determined that, based on the test taker’s responses, it is 95% confident that the test taker is either above the passing standard (or on a higher floor in our analogy) or below it (in the basement!), the exam ends. This could occur at any point between 75 and 265 questions.
To practice effectively as a nurse, you must be able to apply your knowledge of disease processes and pharmacology to patient care. As such, most questions on the NCLEX-RN are at the application level of Bloom’s taxonomy of cognitive ability or higher, which includes analyzing, evaluating, and creating.
The exam is centered around client needs, which are separated into four categories: Safe and Effective Care Environment, Health Promotion and Maintenance, Psychosocial Integrity, and Physiologic Integrity. Physiological Integrity is further separated into four subcategories: Physiological Adaptation, Reduction of Risk Potential, Pharmacological and Parenteral Therapies, and Basic Care and Comfort.
Additionally, nearly all questions incorporate one of the Integrated Processes, which include Nursing Process, Caring, Communication and Documentation, Teaching/Learning, and Culture and Spirituality.
Safe and Effective Care Environment: 20%
Questions covering the creation of a Safe and Effective Care Environment fall into two categories: a) Management of Care and b) Safety and Infection Control.
Arguably the most significant role of the registered nurse is the Management of Care. This crucial part of nursing is reflected in the percentage of questions it represents: roughly 20%, which is more than any other category. You will likely see questions about the legalities associated with nursing: advanced directives, confidentiality, client rights, informed consent, and legal rights and responsibilities. End-of-life care issues such as life planning, self-determination, and organ donation are sure to be covered as well. Case management, advocacy, referrals, and interdisciplinary collaboration are important topics in this section.
Also, you will see quite a few questions covering prioritization of care, task delegation, and supervising other team members. Be prepared to answer questions about performance/quality improvement processes.
Here’s a sample question to try:
Sample Question 1
The nurse receives shift report on four patients. Which patient will the nurse assess first?
48-year-old patient who needs preop teaching prior to surgery at 0800
73-year-old alert and oriented x 3 patient who calls out asking where she is
56-year-old patient who needs a blood glucose check prior to eating breakfast
66-year-old patient status post bowel resection and ostomy requesting pain medication
What’s the correct answer?
For prioritization questions like these on the NCLEX-RN, first use your ABCs: Airway, Breathing, Circulation. If the ABCs don’t apply, switch to Maslow’s Hierarchy of Needs.
If you have experience working in a hospital, you may think that providing preop teaching prior to surgery at 0800 should be completed first because the hospital waits for no one. However, the NCLEX hospital is different from a normal hospital. You have all the time, equipment, and unlicensed assistive personnel you need. Therefore, in NCLEX world, your patient’s surgery will wait until you and the patient are ready (as in, after the teaching is completed).
Additionally, in the NCLEX hospital, your diabetic patient will not receive a tray until after you have checked their blood glucose level, so this important task can wait until after you have assessed the patient with decreasing level of consciousness.
And although pain control is an important nursing consideration, a possible change in level of oxygenation must be assessed prior to administering pain medication.
This means the correct answer is 2. The 73-year-old patient who had been previously alert and oriented to person, place, and time (A&O x 3) is now presumably only alert and oriented to person and time. This decrease in level of consciousness may reflect a decrease in oxygenation or other serious condition and must be assessed immediately by the RN.
Let’s try another question:
Sample Question 2
The 28-year-old patient is brought via ambulance to the emergency department following a motor vehicle accident. The patient is unconscious and requires life-saving surgery. Her boyfriend is brought to the ED as well with bilateral femur fractures. Who should sign the consent form for the unconscious patient’s surgery?
The patient should be stabilized so that she can sign the consent form
The consent form does not need to be signed in life-threatening situations
The patient’s mother or next of kin should be contacted to sign the consent form
The patient’s boyfriend should sign the consent form as the patient’s emergency contact
Let’s break this down:
In emergencies when the patient cannot consent to or refuse treatment, the physician is charged with acting in the best interest of the patient. That is, if the physician is reasonably sure the patient will die or be significantly disabled without treatment, he or she has a responsibility to provide such life-saving measures as necessary despite not having a signed consent form. Therefore, no consent is necessary at this time. Therefore, option 2 is again the right choice.
Reviewing the remaining answer choices:
1) As the patient requires life-saving interventions, it would not be appropriate to simply stabilize the patient.
3) Contacting a mother or next of kin to sign the consent form wastes valuable time since no consent is necessary in emergencies.
4) The boyfriend has no legal right to sign the consent form.
Safety and infection control questions represent around 12% of the questions you will see on the NCLEX-RN. These questions cover the protection of clients and healthcare providers from hazards associated with healthcare settings and the environment.
Be familiar with standard precautions, advanced precautions for prevention of microorganism transmission, how to handle potentially infectious/hazardous materials, and surgical asepsis. Ergonomics and equipment safety may make an appearance, also.
Security and emergency response plans are touched on in a few questions. Injury/error prevention and reporting make excellent question topics. Patient safety considerations including safety in the home and restraint use should also be reviewed.
Ready for another question? Here it is:
Sample Question 3
The nurse is planning care for a patient with Acquired Immunodeficiency Syndrome (AIDS) due to a Human Immunodeficiency Virus (HIV) infection. Which transmission precautions should the nurse utilize when caring for this patient?
Droplet precautions (1) are used for patients with bacterial meningitis, pertussis, and influenza; HIV is not spread via coughing and sneezing. Contact precautions (2) are important for patients with MRSA or RSV; HIV does not transmit by merely touching a patient’s skin. Airborne precautions (3) are necessary if a patient has chickenpox or measles; HIV is not spread through the air. Therefore, standard, or universal, precautions (4) are appropriate for a patient with HIV, which is spread by invasive contact with infected bodily fluids.
Sample Question 4
A fire breaks out in the nursing unit. Which patient should be evacuated first?
65-year-old bedridden patient with dementia
74-year-old patient with pneumonia superimposed on COPD
82-year-old patient with right-sided paralysis and significant confusion
54-year-old patient on postoperative day one following a right above the knee amputation
In the event of a fire on the nursing unit, ambulatory patients should be evacuated first. Based on the descriptions, the 74-year-old patient with pneumonia and COPD appears to be the most able to evacuate the unit with the least amount of assistance. The patient one-day postop following right AKA would be evacuated next because they could likely use crutches to evacuate. The older patient with hemiparesis and confusion would be evacuated next. Lastly, the bedridden patient would be evacuated.
Health Promotion and Maintenance: 9%
A fairly self-explanatory topic, Health Promotion and Maintenance questions represent roughly 9% of the questions you will see on the NCLEX-RN. These questions deal with topics related to disease prevention, health optimization, and expected growth and development. Lifespan considerations such as developmental stages, maternity and newborn nursing, and the aging process are tested in this section. Be comfortable answering questions regarding risky behaviors and lifestyle choices. Physical assessment and health screening techniques make great test questions, also.
Here’s another question to test yourself in this area:
Sample Question 5
The nurse is preparing a community health class on reproductive health. Which secondary disease prevention strategies should the nurse include in the talk? Select all that apply.
Papanicolaou (Pap) smear
Condom use during intercourse
Regular mammograms after age 50
Human papilloma virus (HPV) vaccine
First, notice that the instructions say to select all that apply. Be sure to read the instructions carefully on the NCLEX-RN so that you don’t lose points for not selecting enough answers. In this question, we can see that options 1, 3, and 5 are all correct.
Secondary prevention strategies assist with the early detection and treatment of disease. These include breast self-exams, pap smears, and mammograms. Primary prevention strategies prevent disease before it occurs. These include prophylactic mastectomies, condom use, and HPV vaccines.
You might find this question tricky if you don’t read it closely enough. Obviously, all of these topics are appropriate for a community health class on reproductive health. However, the question specifically asks for secondary disease prevention strategies.
Sample Question 6
The nurse is supervising a nursing student who is performing a focused assessment of a patient’s abdomen. Which action, if performed by the nursing student, would prompt the nurse to intervene immediately?
The nursing student percusses the abdomen prior to palpating it
The nursing student inspects the abdomen before auscultating it
The nursing student palpates the abdomen prior to auscultating it
The nursing student auscultates the abdomen prior to percussing it
The correct order of an abdominal assessment is inspection, auscultation, percussion, and palpation. This is different from all other assessments in which the nurse inspects, palpates, percusses, and then auscultates. The alteration is significant because palpation can cause falsely positive bowel sounds.
Therefore, the nurse should intervene if he observes the nursing student attempting to palpate the abdomen prior to auscultating it (option 3 above). No intervention is necessary if the nursing student inspects, then auscultates, percusses, and finally palpates the patient’s abdomen.
Psychosocial Integrity: 9%
Another 9% of questions cover topics related to psychosocial integrity. Be prepared to identify aspects of therapeutic environments, crisis interventions, and behavioral interventions. You will need to know how to provide culturally sensitive care and be aware of how culture, religion, and spirituality influence health choices.
There will certainly be questions regarding end-of-life care as well as supporting patients and family members through grief and loss. Concepts associated with abuse and neglect might make an appearance. Chemical dependencies and substance abuse disorders, among other mental health topics, will be covered as well.
You might see questions that deal with family dynamics and support systems. Coping mechanisms and stress management make great NCLEX-RN questions. Surprisingly, sensory and perceptual alterations are also included in this section.
Sample Question 7
The nurse enters the room of a patient with stage 1 cancer to see his wife crying softly by the bed while the patient sleeps. Which response by the nurse is most appropriate?
“I’ll call the chaplain to come talk to you.”
“Please don’t be scared, ma’am. It could be so much worse!”
“I’ll sit with you awhile. You can tell me what’s bothering you, if you’d like.”
“I’m sorry you’re scared, ma’am, but we caught the cancer He’s going to be ok!”
Although the patient may wish to speak with a chaplain, the nurse should not assume that initially. The most effective response by the nurse is to “offer self.” That is, sit with the patient’s wife and allow her to direct the conversation (option 3). The nurse should not assume why the patient’s wife is crying. It’s vital the nurse does not minimize the patient’s wife’s feelings by saying it could be worse. Additionally, even if it’s likely the patient will be okay since the cancer was caught early, that is a promise the nurse cannot and should not make.
Now try this question:
Sample Question 8
The nurse enters the room to find the patient unconscious and bradypneic with a small syringe still in his arm. The nurse alerts the physician and anticipates administering which medication?
Explanation: The patient appears to be suffering from a heroin overdose, which is treated with Narcan (option 2). Mucomyst is used to treat a Tylenol overdose. Protamine is administered if the patient receives too much heparin. Ativan is a phenobarbital that would worsen the patient’s symptoms, not improve them.
Physiological Integrity – Basic Care and Comfort: 9%
Basic Care and Comfort questions make up another 9% of the NCLEX-RN. They cover assistance with daily living activities such as hygiene, nutrition, elimination, and sleep concepts. Questions regarding mobility and assistive devices fall in this category. Additionally, non-pharmacological interventions for pain and discomfort are frequently covered in the NCLEX-RN.
Sample Question 9
The patient tells the nurse, “My neck is so stiff after sleeping on those pillows.” Which comfort intervention should the nurse implement first?
Instruct the patient to stretch the neck for a minute every 10 minutes
Provide the patient with a heating pack wrapped in a towel for the neck
Contact the patient’s provider for an order for a muscle relaxing medication
Ask an unlicensed personnel to bring the patient an ice pack for the patient’s neck
What would you do?
Ice may be helpful after the muscles are loosened and stretched, but it’s not an appropriate initial intervention. Similarly, pharmacological interventions may be required, but only after non-pharmacological interventions are attempted first. The first intervention should be to provide a hot pack for the patient with a stiff neck as the heat will help loosen tight muscles. After the muscles are loosened, then the patient can stretch her neck.
Physiological Integrity – Physiological Adaptation: 14%
Physiological adaptation questions comprise about 14% of the NCLEX-RN. They cover alterations in body systems, the pathophysiology of disease, and the management of those illnesses. These alterations may include fluid and electrolyte imbalances, changes in hemodynamics, and medical emergencies. Additionally, you should be able to answer questions on any unexpected responses to therapies.
This is a typical example question on this topic:
Sample Question 10
The nurse is caring for a patient in the postoperative period following abdominal surgery. The patient suddenly has difficulty breathing, terrible chest pain with each breath, and states, “I’m not sure why, but I feel like something terrible is about to happen.” The nurse is most concerned about which postoperative complication?
Although patients are at risk for pneumonia following surgery, it usually presents with a gradual, rather than acute, onset of symptoms. Pneumothorax is not a common postop complication.
However, following anesthesia and surgery, patients are at risk of blood clots due to immobility and venous stasis. If clots that form in the periphery break loose, they become emboli that can land in the lungs, blocking blood flow. Patients with acute pulmonary embolism may present with dyspnea, pleuritic chest pain, and a sense of impending doom. The patient’s symptoms in this case more closely match with an acute PE rather than and MI, so choice 3 is the best answer.
Sample Question 11
The patient presents to the emergency department following a massive motor vehicle accident. The patient has significant bruising to the chest and abdomen from the steering wheel but is able to move all extremities on command. The nurse notes the following vital signs and assessment data: heart rate 114 beats per minute, respiratory rate 20 breaths per minute, blood pressure 92/48 mmHg, cap refill 4 seconds, pulse weak. The nurse understands this patient is experiencing which condition?
The patient’s vital signs (hypotension, tachycardia, poor perfusion) suggest the patient is in shock. Striking the steering wheel in an MVA can cause serious internal bleeding leading to hypovolemic shock (choice 4). The significant bruising to the chest and abdomen supports this conclusion. Cardiogenic shock can occur following an MI. Neurogenic shock occurs after a spinal cord injury; the patient is able to move all extremities. Septic shock occurs when the patient has a bloodstream infection, which is unlikely in this case.
Physiological Integrity – Reduction of Risk Potential: 12%
Questions that fall under the Reduction of Risk Potential heading (12% of the NCLEX-RN) are designed to test your knowledge of how to decrease complications related to procedures and treatments or existing health conditions. Diagnostic tests, lab tests and values, abnormal vital signs, and system-specific assessments may be encountered. Therapeutic procedures nurses perform or assist with are fair game as question topics. Be familiar with the potential for body system alterations, complications from tests/procedures/treatments, and health alterations.
Sample Question 12
The nurse is reviewing the complete blood cell count (CBC) values of a patient recently admitted to the unit. Which lab value would prompt the nurse to notify the provider immediately?
Hemoglobin = 6.3 gm/dL
Platelets = 340,000 cells/ mcL
White blood cell count = 6,000 cells/mcL
Red blood cell count = 5 million cells/mcL
The patient’s platelets, white blood cell count, and red blood cell count are all within normal limits.
So it’s the patient’s dangerously low hemoglobin in this case that would prompt immediate action.
Here’s a similar type of question:
Sample Question 13
The unlicensed assistive personnel has obtained vital signs on a 32-year-old patient. Which vital sign does the nurse find most concerning?
Blood pressure 138/92 mmHg
Heart rate 104 beats per minute
Oxygen saturation 94% on room air
Respiratory rate 32 breaths per minute
The normal respiratory rate for an adult is 12-18 breaths per minute. A respiratory rate of 32 breaths per minute is concerning and should be assessed by the nurse. Although a blood pressure of 138/92 and a heart rate of 104 is slightly elevated, these vital signs are not as concerning as the patient’s tachypnea. An oxygen saturation of 94% on room air is on the low end of normal and should be monitored, but is less concerning than the patient’s tachypnea. Therefore, option 4 is the best answer.
Physiological Integrity – Pharmacological and Parenteral Therapies: 15%
A large part of nursing care is administering medications safely. Questions relating to Pharmacological and Parenteral Therapies (15% of exam) include the expected outcomes, adverse effects, contraindications, drug interactions, routes, and side effects of medications. Total parenteral nutrition and other intravenous therapies are covered also.
Techniques of medication administration and dosage calculation make great NCLEX-RN questions. Don’t forget that pediatric dosing is by weight—as in, mg/kg. Be familiar with blood product administration and the use of central venous access.
Sample Question 14
The 4-year-old patient with bacterial meningitis has an order to receive vancomycin 20mg/kg IV q6h. The patient weighs 40 pounds. The vancomycin is dispensed in a 5mg/mL solution. How many milliliters will the nurse administer with each dose? Record your answer to the 10th decimal point.
Since this is our first calculation question, let’s start with a quick reminder that you won’t be allowed to bring your own calculator into the NCLEX-RN exam with you. But an on-screen calculator is provided. Consider practicing questions ahead of time using that calculator to familiarize yourself with how it works before test day.
Okay, now let’s jump in:
First, you must determine the patient’s weight in kilograms.
Second, determine how many milligrams the patient will receive by weight.
Lastly, use the dispensed concentration to determine how many milliliters the nurse will administer per dose.
Reorganize your equation to make it simpler:
Sample Question 15
The neonatal patient with Type A negative blood type has been ordered to receive 15mL/kg of packed red blood cells. The blood bank sends the nurse packed red blood cells with the blood type of O positive. What is the appropriate action by the nurse?
Administer the blood because neonates don’t have transfusion reactions
Administer the blood because O positive blood is considered the universal donor
Hold the blood and return it to the blood bank because the patient requires Rh negative blood
Hold the blood and return it to the blood bank because the patient can only receive Type A negative blood
The appropriate response by the nurse is to return the blood to the blood bank because a neonate with A negative blood type requires Rh negative blood (option 3). The blood types the patient can receive are A negative and O negative, not just A negative. Although babies are less likely to have transfusion reactions due to fewer antibodies in the blood, blood incompatibilities are a different problem. O negative, not O positive, is considered to be the universal donor.
Nursing school has provided you with the necessary knowledge to pass the NCLEX-RN in 75 questions. The most crucial step now is to become comfortable with how the NCLEX-RN asks questions. Answer as many questions as you can get your hands on to prepare yourself for the big day. It’s sure to be challenging, but being able to add those two little letters (RN!) to your signature makes the struggle worthwhile!