The Next Generation NCLEX (NGN) tests clinical judgment as well as knowledge. Alongside traditional multiple-choice questions, candidates see case studies and new item types such as extended multiple response, matrix questions, drop-down cloze and bow-tie items. Practising with realistic questions, and understanding the reasoning behind each answer, is one of the best ways to prepare.
These 20 original practice items are written in NCLEX style. They are not actual NCLEX questions. Use them to test your thinking and review rationales carefully.
Part 1: Prioritisation and safety
1. The nurse receives handover for four clients. Which client should the nurse see first?
A. A client 2 days post-appendectomy requesting pain medication, pain 5/10
B. A client with COPD with SpO2 of 90% on 2 L/min oxygen
C. A client with a new onset of restlessness and respiratory rate of 30 after a hip replacement yesterday
D. A client with diabetes whose breakfast tray has arrived
Answer: C. New restlessness and tachypnoea after orthopaedic surgery may indicate pulmonary embolism or other acute deterioration. A SpO2 of 90% may be the target range for a client with COPD.
2. A client receiving a blood transfusion develops chills, back pain and a temperature rise 10 minutes after the start. What is the nurse’s first action?
A. Slow the transfusion
B. Stop the transfusion and maintain IV access with normal saline using new tubing
C. Give paracetamol
D. Notify the blood bank
Answer: B. Suspect an acute haemolytic reaction. Stop immediately, keep the vein open with saline through new tubing, then notify the provider and blood bank.
3. Which task can the registered nurse appropriately delegate to an unlicensed assistive personnel (UAP)?
A. Assessing a newly admitted client
B. Teaching a client about insulin injections
C. Measuring and recording vital signs of a stable client
D. Evaluating a client’s response to pain medication
Answer: C. Assessment, teaching and evaluation remain the RN’s responsibility.
4. A client on contact precautions for MRSA is being transferred. Which action is most important?
A. Remove the client’s gown before transport
B. Inform the receiving unit of the isolation status
C. Give prophylactic antibiotics
D. Use droplet precautions
Answer: B. Communicating isolation status prevents transmission.
5. A client becomes unresponsive and pulseless. After calling for help, the nurse should:
A. Start chest compressions
B. Give two rescue breaths and check for a pulse again
C. Obtain a 12-lead ECG
D. Start an IV line
Answer: A. High-quality compressions should begin immediately in adult cardiac arrest.
Part 2: Pharmacology
6. A client taking warfarin has an INR of 5.2 and no bleeding. The nurse should anticipate:
A. Continuing the current dose
B. Holding warfarin and notifying the provider
C. Giving protamine sulfate
D. Doubling the next dose
Answer: B. The INR is above the usual therapeutic range. Vitamin K may be ordered. Protamine reverses heparin, not warfarin.
7. Which assessment is most important before administering IV furosemide?
A. Blood glucose
B. Serum potassium and blood pressure
C. Temperature
D. Pupil size
Answer: B. Loop diuretics can cause hypokalaemia and hypotension.
8. A client receiving morphine has a respiratory rate of 8 and is difficult to rouse. The nurse prepares to give:
A. Flumazenil
B. Naloxone
C. Atropine
D. Ondansetron
Answer: B. Naloxone reverses opioid-induced respiratory depression; monitor for recurrence.
9. Which statement by a client starting lisinopril indicates a need for further teaching?
A. “I’ll change positions slowly.”
B. “I’ll report swelling of my lips or tongue.”
C. “I can use salt substitutes freely.”
D. “A dry cough is a possible side effect.”
Answer: C. Many salt substitutes contain potassium, and ACE inhibitors can raise potassium.
10. A client with type 1 diabetes takes rapid-acting insulin lispro at 07:30. When is the client most at risk of hypoglycaemia?
A. 07:45
B. 08:30 to 09:30
C. 13:00
D. 19:00
Answer: B. Rapid-acting insulin peaks about 1 to 2 hours after injection.
Part 3: Maternal, child and mental health
11. A woman receiving magnesium sulfate for pre-eclampsia has absent deep tendon reflexes and a respiratory rate of 10. The nurse should first:
A. Increase the infusion
B. Stop the magnesium infusion
C. Give oxytocin
D. Encourage oral fluids
Answer: B. These are signs of magnesium toxicity. Stop the infusion, notify the provider and prepare calcium gluconate.
12. A 2-year-old has a barking cough, inspiratory stridor at rest and suprasternal retractions. Which is the priority?
A. Give oral antibiotics
B. Keep the child calm and prepare for nebulised adrenaline (epinephrine) and steroids as prescribed
C. Examine the throat with a tongue depressor
D. Encourage the child to lie flat
Answer: B. This suggests moderate to severe croup. Avoid distressing the child.
13. A client with depression who has been withdrawn suddenly appears calm and gives away possessions. The nurse should:
A. Document improvement
B. Assess directly for suicidal thoughts and plans
C. Encourage more social activity
D. Reduce observation
Answer: B. A sudden lift in mood with giving away possessions may indicate a decision to attempt suicide.
14. A newborn’s 1-minute APGAR: heart rate 110, slow irregular breathing, some flexion, grimace, body pink with blue extremities. The score is:
A. 5
B. 6
C. 7
D. 8
Answer: B. Heart rate over 100 = 2; slow irregular respirations = 1; some flexion = 1; grimace = 1; acrocyanosis = 1. Total 6.
Part 4: Next Generation NCLEX styles
Case study (questions 15 to 18): A 68-year-old client is admitted with pneumonia. Temperature 39.1°C, heart rate 118, BP 92/54, respiratory rate 26, SpO2 89% on room air. The client is newly confused. Lactate 3.4 mmol/L. White cell count 17 × 10⁹/L.
15. Extended multiple response: Which findings require immediate follow-up? Select all that apply.
A. Temperature 39.1°C
B. BP 92/54
C. Respiratory rate 26
D. New confusion
E. Lactate 3.4 mmol/L
F. Age 68
Answer: A, B, C, D, E. These are signs of sepsis with possible hypoperfusion. Age is a risk factor but not an abnormal finding needing follow-up in itself.
16. Drop-down cloze: The client is most likely experiencing ______ as evidenced by ______ and ______.
Answer: sepsis, as evidenced by hypotension and an elevated lactate (other acceptable cues include tachypnoea and altered mental status).
17. Bow-tie: Identify the condition, two actions, and two parameters to monitor.
- Condition: sepsis
- Actions to take: obtain blood cultures and administer broad-spectrum antibiotics as prescribed; administer IV fluid bolus as prescribed; apply oxygen
- Parameters to monitor: blood pressure (mean arterial pressure), urine output, lactate, mental status
18. After treatment, which finding indicates the client’s condition is improving?
A. Urine output 15 mL/hour
B. Lactate decreasing to 1.6 mmol/L
C. Respiratory rate 30
D. New mottled skin
Answer: B. Falling lactate suggests improving tissue perfusion.
19. Matrix (multiple choice): For each intervention, indicate whether it is indicated or contraindicated for a client with a suspected stroke within the thrombolysis window, before imaging.
- Check blood glucose: indicated
- Give aspirin before CT: contraindicated (haemorrhage must be excluded first)
- Keep NPO until swallow screen: indicated
- Record time last known well: indicated
20. A client with heart failure gains 2 kg in 2 days. Which action is most appropriate?
A. Encourage more fluids
B. Assess for oedema and lung sounds and notify the provider
C. Document as normal
D. Reduce the client’s diuretic
Answer: B. Rapid weight gain indicates fluid retention.
NCLEX test-taking tips
- Airway, breathing, circulation usually come first in prioritisation.
- Acute over chronic, unstable over stable, actual over potential.
- Safety first: choose answers that prevent harm.
- Assess before intervening, unless the situation is an emergency requiring immediate action.
- Read the stem carefully: “needs further teaching” means you’re looking for the incorrect statement.
- For NGN case studies, recognise cues, analyse, prioritise hypotheses, generate solutions, take action and evaluate outcomes, following the NCSBN Clinical Judgment Measurement Model.