The NCLEX repeats the same high-yield patterns in Pharmacology and Med-Surg. If you know the core scenarios and why one action is safest, you can spot the right answer fast. Use this guide to practice the decisions you’ll make at the bedside.
How to use this guide
Focus on safety and priorities. The exam rewards actions that protect the airway, breathing, and circulation (ABCs), prevent harm, and use the least invasive measures first. Assess before you act—unless the patient is unstable or in obvious danger.
Use structured thinking. Maslow (physiologic before psychosocial), acute before chronic, unstable before stable, new post-op before routine. Ask: Will this action change the outcome in the next few minutes?
Know critical labs and drug levels. You cannot make safe choices without numbers. Learn ranges that trigger “hold the med,” “call the provider,” or “intervene now.”
Pharmacology: The 25 high‑yield questions
Question: A client on warfarin has an INR of 4.2 and bleeding gums. What is the priority? Answer: Hold warfarin and notify the provider. Why: INR is above the 2–3 goal, so hemorrhage risk is high. Vitamin K may be ordered for significant bleeding.
Question: A heparin infusion patient has an aPTT 2.8 times baseline. What do you do? Answer: Stop heparin, assess for bleeding, prepare protamine. Why: Therapeutic aPTT is 1.5–2.5× control. Over-anticoagulation needs reversal.
Question: A patient on digoxin reports nausea and yellow vision; HR is 58. Next step? Answer: Hold digoxin and check level. Why: HR under 60 and classic toxicity signs mean the dose is unsafe. Therapeutic level is 0.8–2.0 ng/mL.
Question: A client takes furosemide and digoxin; K is 3.0 mEq/L. Best action? Answer: Replace potassium and hold digoxin. Why: Hypokalemia increases digoxin toxicity and dysrhythmia risk.
Question: A client on lisinopril develops a persistent cough. What now? Answer: Notify the provider about switching to an ARB. Why: ACE inhibitor cough is common; ARBs do not raise bradykinin.
Question: A patient on an ACE inhibitor has lip/tongue swelling. Priority? Answer: Manage airway and prepare epinephrine. Why: Angioedema can rapidly obstruct the airway.
Question: Before giving metoprolol, vitals are HR 56, BP 98/58. What do you do? Answer: Hold the dose and assess. Why: Beta-blockers lower heart rate and blood pressure. HR under 60 or symptomatic hypotension is unsafe.
Question: A client with chest pain took sildenafil this morning. Give nitroglycerin? Answer: No. Withhold and notify the provider. Why: Nitrates with PDE5 inhibitors can cause life-threatening hypotension for 24–48 hours.
Question: You must mix regular insulin and NPH in one syringe. Which do you draw first? Answer: Regular (clear) before NPH (cloudy). Why: Prevents contaminating regular insulin with NPH, which changes onset.
Question: A patient on NPH insulin has tremors at 3 PM. Cause? Answer: NPH peak hypoglycemia. Why: NPH peaks 4–12 hours after morning dose, so mid-afternoon lows are common.
Question: A sick type 1 diabetic asks whether to stop insulin. Best teaching? Answer: Keep basal insulin; check glucose/ketones often; hydrate. Why: Illness raises glucose; stopping insulin risks DKA.
Question: When do you draw a vancomycin trough? Answer: Just before the 4th dose. Why: Steady state is reached by then. High troughs (>20) increase nephrotoxicity risk.
Question: A patient on gentamicin develops tinnitus and rising creatinine. What now? Answer: Hold the dose and notify the provider. Why: Aminoglycosides are oto- and nephrotoxic; early action prevents permanent damage.
Question: Teaching for tetracycline? Answer: Avoid dairy/antacids; use sun protection; not for pregnancy/children. Why: Chelation blocks absorption; risk of photosensitivity and tooth discoloration.
Question: A client on azithromycin reports palpitations. Concern? Answer: Yes—risk of QT prolongation. Why: Macrolides can trigger torsades, especially with other QT-prolonging drugs.
Question: Fluoroquinolone teaching? Answer: Report tendon pain; avoid antacids; limit sun. Why: Tendon rupture is a serious adverse effect; divalent cations reduce absorption.
Question: Rifampin counseling? Answer: Expect orange fluids; use backup contraception. Why: Harmless discoloration is common; rifampin induces enzymes and lowers hormonal contraceptive efficacy.
Question: Isoniazid key safety points? Answer: Give pyridoxine; avoid alcohol; monitor LFTs. Why: Prevents neuropathy; hepatotoxicity risk rises with alcohol.
Question: Opioid overdose signs (RR 6, pinpoint pupils). First action? Answer: Give naloxone and support airway. Why: Respiratory depression kills; naloxone may need repeat dosing.
Question: Benzodiazepine overdose in a chronic user. Use flumazenil? Answer: Avoid routine use; support airway. Why: Flumazenil can precipitate seizures; use only in select cases.
Question: SSRI plus linezolid: patient has fever, agitation, tremor. What is this? Answer: Serotonin syndrome; stop serotonergic drugs. Why: Excess serotonin causes hyperreflexia and autonomic instability.
Question: MAOI diet rule? Answer: Avoid tyramine (aged cheese, cured meats). Why: Tyramine can trigger hypertensive crisis. Severe headache is an emergency.
Question: Lithium safety? Answer: Maintain fluids/salt; avoid NSAIDs; monitor level 0.6–1.2. Why: Dehydration and NSAIDs raise levels; toxicity causes GI upset, tremor, confusion.
Question: Phenytoin teaching? Answer: Good oral care; no pregnancy; level 10–20; affects birth control. Why: Gingival hyperplasia is common; teratogenic; induces enzymes.
Question: Statin and steroid pearls? Answer: Statins at night; report muscle pain; check LFTs. Steroids: take with food, taper, watch glucose/infection. Why: Maximizes effect and prevents serious harms.
Question: Diuretics and potassium? Answer: Loops/thiazides waste K; monitor and replace. Spironolactone spares K; avoid high-K foods/salt substitutes if K is high. Why: Prevents arrhythmias.
Question: Levothyroxine teaching? Answer: Take in the morning on an empty stomach; lifelong therapy; separate from iron/calcium. Why: Food and cations impair absorption; consistent dosing keeps TSH on target.
Med‑Surg: The 25 high‑yield questions
Question: New chest pain on the unit. First actions? Answer: Assess ABCs, get vitals/ECG, give chewable aspirin if not contraindicated. Why: Early aspirin and ECG improve outcomes; oxygen only if SpO2 is low.
Question: Blood transfusion: fever, back pain, chills. First step? Answer: Stop transfusion; keep IV open with normal saline; notify provider/blood bank. Why: Prevents more antigen exposure and maintains access.
Question: Suspected air embolism during central line care. Position? Answer: Left lateral Trendelenburg. Why: Traps air in the right atrium; prevents it from entering pulmonary circulation.
Question: Chest tube: continuous bubbling in water seal. What does it mean? Answer: Air leak—check connections and occlusive dressing. Why: Persistent bubbling is not normal after initial evacuation.
Question: Trach suctioning technique? Answer: Pre-oxygenate, sterile technique, insert without suction, suction 10–15 seconds, re-oxygenate between passes. Why: Reduces hypoxia and mucosal trauma.
Question: COPD oxygen target? Answer: 88–92%. Why: Excess oxygen can worsen CO2 retention; titrate carefully to symptoms and ABGs.
Question: Pneumonia with unilateral disease—best position? Answer: Good lung down. Why: Gravity improves ventilation/perfusion matching and oxygenation.
Question: Stroke patient arrival: what history matters most? Answer: Last known well time. Why: IV thrombolysis window is about 3–4.5 hours; timing guides therapy.
Question: DKA initial priority? Answer: IV fluids first, then insulin. Why: Severe dehydration impairs perfusion; fluids reduce glucose and help potassium shift safely.
Question: Unconscious hypoglycemic patient without IV access. What now? Answer: Give IM glucagon. Why: It raises glucose quickly; start IV dextrose when access is available.
Question: Diabetes insipidus hallmark? Answer: Large volumes of dilute urine; low specific gravity. Why: ADH deficiency or resistance causes water loss; treat with desmopressin and fluids.
Question: EKG shows peaked T waves in a renal patient. First medication? Answer: IV calcium gluconate. Why: Stabilizes myocardium immediately; then shift K with insulin/dextrose and remove K.
Question: Signs of hypocalcemia? Answer: Trousseau and Chvostek signs, tetany, numbness. Why: Low calcium increases neuromuscular excitability; treat with calcium and vitamin D.
Question: Acute pancreatitis plan of care? Answer: NPO, aggressive IV fluids, pain control, monitor electrolytes. Why: Resting the pancreas and resuscitation reduce autodigestion and complications.
Question: RUQ pain after a fatty meal with fever and positive Murphy sign. Likely condition? Answer: Cholecystitis. Why: Gallbladder inflammation is triggered by fat; Murphy sign localizes RUQ tenderness.
Question: AKI patient asks for ibuprofen for pain. Best response? Answer: Avoid NSAIDs; use alternatives. Why: NSAIDs reduce renal perfusion and worsen kidney injury.
Question: Neutropenic client precautions? Answer: Hand hygiene, private room, mask when leaving, no fresh flowers/raw produce. Why: Low ANC means minor exposures can cause severe infection.
Question: C. difficile isolation? Answer: Contact precautions; gown and gloves; wash hands with soap and water. Why: Spores resist alcohol hand gel; environmental cleaning must be sporicidal.
Question: Correct PPE sequence? Answer: Don: gown, mask, goggles, gloves. Doff: gloves, goggles, gown, mask. Why: Remove the dirtiest items first to reduce contamination.
Question: Prevent post-op atelectasis? Answer: Incentive spirometer, early ambulation, cough/deep breathe, splint incision. Why: Expands alveoli and clears secretions.
Question: TPN management when the bag runs out? Answer: Hang D10 and call pharmacy. Why: Abrupt stop causes hypoglycemia; dextrose prevents a drop.
Question: Tube feeding residual is 600 mL. What now? Answer: Hold feeding, return residual, reassess later; keep HOB 30–45°. Why: High residuals increase aspiration risk.
Question: Pressure injury prevention on a bedbound client? Answer: Reposition q2h, offload heels, manage moisture, adequate protein/calories. Why: Reduces pressure, shear, and tissue hypoxia.
Question: Heart failure client gains 3 lb in 24 hours. Action? Answer: Notify the provider; review sodium/fluid intake; assess symptoms. Why: Rapid weight gain signals fluid overload and decompensation.
Question: Delegation question: Who can the UAP safely help? Answer: Stable clients with routine ADLs and standard vitals. Why: RNs do assessment, teaching, evaluation, and unstable care; LPNs give routine meds to stable clients.
Rapid labs and levels to know
- Potassium: 3.5–5.0 mEq/L (dysrhythmia risk outside this range)
- Sodium: 135–145 mEq/L (neuro changes when abnormal)
- Calcium total: 8.5–10.5 mg/dL; Magnesium: 1.5–2.5 mEq/L
- BUN: 7–20 mg/dL; Creatinine: ~0.6–1.3 mg/dL
- WBC: 5,000–10,000/µL; Platelets: 150,000–400,000/µL
- Hgb: ~12–18 g/dL (varies by sex); Hct: ~36–54%
- Glucose fasting: 70–100 mg/dL; A1c: under 7% (most adults)
- aPTT (heparin): 1.5–2.5× control (control ~25–35 s)
- INR (warfarin): 2–3 (2.5–3.5 for some valves)
- Digoxin: 0.8–2.0 ng/mL; Lithium: 0.6–1.2 mEq/L
- Phenytoin: 10–20 mcg/mL; Theophylline: 10–20 mcg/mL
- Vancomycin trough: 10–20 mcg/mL (per institution)
Fast test‑taking tactics
- Pick the action that protects life in the next minute. Airway obstruction beats everything.
- Assess before you medicate or call, unless there is active bleeding, anaphylaxis, or severe instability.
- Least invasive, most effective first. Reposition, oxygen, and reassess often come before drugs.
- Match the abnormal finding to the drug. High INR? Hold warfarin. Low K on digoxin? Replace K.
- Eliminate unsafe options. If two answers are right, pick the one that addresses the priority threat.
Work through these 50 scenarios until your responses feel automatic. On test day, you will see new wording, but the same decisions. If you can justify your choice with a safety reason and a lab or assessment cue, you are on the right answer.
I am a Registered Pharmacist under the Pharmacy Act, 1948, and the founder of PharmacyFreak.com. I hold a Bachelor of Pharmacy degree from Rungta College of Pharmaceutical Science and Research. With a strong academic foundation and practical knowledge, I am committed to providing accurate, easy-to-understand content to support pharmacy students and professionals. My aim is to make complex pharmaceutical concepts accessible and useful for real-world application.
Mail- Sachin@pharmacyfreak.com