Free NCLEX-RN Practice Test: 70 Questions With Rationales

This free NCLEX-RN practice test includes 70 original, unofficial questions with answers and rationales, including three six-question clinical-judgment cases. It follows the 2026 RN test-plan categories; this fixed practice set is not the computer-adaptive NCLEX and does not predict passing.

Question 1

A charge nurse on a medical unit receives report on four clients at the start of the shift. Which client should the nurse assess first?

A. A client two days after total hip arthroplasty with unchanged incisional pain rated 6 on a 0-to-10 scale and otherwise stable assessment findings
B. A client with cirrhosis who was alert yesterday and is now difficult to rouse
C. A client with type 2 diabetes whose morning capillary glucose is 212 mg/dL, within this client's recent pattern, with no acute symptoms
D. A client with COPD whose oxygen saturation is 90% on 2 L/min by nasal cannula, unchanged from baseline and within the prescribed target of 88%-92%

Answer and rationale — Question 1

Correct answer:

A new decline in arousability is an acute neurologic change that threatens the client's ability to protect the airway. In cirrhosis it can signal hepatic encephalopathy. An acute change in a system that affects airway, breathing, or circulation outranks findings that are abnormal but expected or stable.

Why the other choices do not fit:

A. Pain of 6 needs treating, and soon, but the question describes unchanged pain with otherwise stable findings, not new deterioration.
C. 212 mg/dL is above target and needs follow-up, but no acute symptoms or change from this client's recent pattern is described.
D. This client is within the explicitly prescribed oxygen target and has no change from baseline. A new decline or increased work of breathing would change the priority.

Teaching point. Go to the new, unexpected change in a system that affects airway, breathing, or circulation, not the most alarming-looking number on the page.

Management of Care · RN26-A-001

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: NIDDK: Symptoms & Causes of Cirrhosis — Symptoms and complications, including confusion

Question 2

On the first day after emergency abdominal surgery for a perforated bowel with intra-abdominal infection, a client becomes newly confused. Vital signs are temperature 38.6 C (101.5 F), heart rate 118/min, respirations 26/min, blood pressure 94/56 mm Hg. Which problem should the nurse prioritize as the most likely explanation?

A. Uncontrolled incisional pain
B. Sepsis
C. Situational anxiety about the surgery
D. Normal postoperative recovery

Answer and rationale — Question 2

Correct answer:

Fever, tachycardia, tachypnea, hypotension, and new confusion appearing together after abdominal surgery raise concern for infection with organ dysfunction. New confusion should not be dismissed as post-anesthesia fogginess in this setting.

Why the other choices do not fit:

A. Pain may contribute to tachycardia, but it does not adequately explain this entire cluster in a client with a known source of infection.
C. Anxiety does not adequately explain fever, hypotension, and new confusion together.
D. Hypotension with fever and new confusion is not part of an ordinary first postoperative day.

Teaching point. Read the cluster together: suspected infection, abnormal perfusion, and a new mental-status change need urgent assessment and treatment.

Management of Care · Prioritize hypotheses · RN26-A-002

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: SCCM/ESICM: Surviving Sepsis Campaign Adult Guidelines — Filterable recommendations: biomarkers, blood culture, blood lactate, resuscitation, antibiotic initiation, serial lactate and source control

Question 3

Facility policy and the assistive personnel's demonstrated competency permit routine vital-sign collection. Which task is most appropriate for the registered nurse to assign to that person?

A. Obtaining vital signs on a stable client one day after a hernia repair
B. Providing the initial teaching on how to use an incentive spirometer
C. Performing the admission assessment on a newly arrived client
D. Evaluating whether a client's pain medication was effective

Answer and rationale — Question 3

Correct answer:

Routine vital signs on a stable client are a predictable task within the stated role and competency. The RN still reviews the values and decides what they mean. NCSBN distinguishes assigning routine role activities from delegating a nursing activity outside the person's traditional role.

Why the other choices do not fit:

B. Initial teaching and deciding what this client needs to learn require nursing judgment; this is not the same as reinforcing an established instruction.
C. The admission nursing assessment is not assigned to assistive personnel. The RN performs it.
D. Evaluation of a client's response to an intervention is a nursing judgment and stays with the RN.

Teaching point. Assign or delegate within the applicable role, policy, and demonstrated competency. Nursing assessment, initial teaching, and evaluation require nursing judgment.

Management of Care · RN26-A-003

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: NCSBN/ANA: National Guidelines for Nursing Delegation — Definitions and responsibilities, pp. 3-4

Question 4

For a surgeon-performed procedure, facility policy assigns the surgeon the procedure-specific informed-consent discussion and permits the bedside RN to witness the signature. Which nursing actions are correct? Select all that apply.

A. The nurse may witness the client's signature on the consent form.
B. The nurse checks whether the client can describe the procedure, its risks, and alternatives in their own words.
C. The bedside nurse substitutes their own explanation for the surgeon's procedure-specific risks, benefits, and alternatives discussion.
D. The nurse notifies the provider if the client's understanding appears incomplete.
E. The nurse obtains the spouse's signature instead of the decision-capable adult client's voluntary consent.

Answer and rationale — Question 4

Correct answer:

A, B, D

Witnessing the signature under the stated policy, checking the client's understanding, and escalating gaps to the surgeon support informed consent. Consent also requires decision-making capacity and a voluntary choice.

Why the other choices do not fit:

C. For this procedure and policy, the surgeon is responsible for the procedure-specific discussion. The nurse should not substitute an incomplete explanation or proceed with unanswered questions.
E. A decision-capable adult makes their own choice. Being alert and oriented alone would not establish decision-making capacity, and a spouse is not an automatic substitute for the client.

Teaching point. A signature does not replace an informed, voluntary decision. Check understanding and obtain the responsible clinician's clarification before the procedure.

Management of Care · RN26-A-004

Castleport practice scoring: Add one per correct selection; subtract one per incorrect selection; minimum zero. Maximum: 3 practice points.

Source: AMA Code of Medical Ethics: Informed Consent — Opinion 2.1.1

Question 5

A client who now lacks decision-making capacity develops respiratory failure. The client has an applicable, valid advance directive declining intubation and an active do-not-intubate order; neither has been revoked. The client's adult daughter insists on intubation. Which action should the nurse take?

A. Prepare for intubation because the family has requested it
B. Ask the daughter to sign a consent form for intubation
C. Follow the client's documented directive, notify the provider, and offer the family support and an ethics consultation
D. Explain that the spouse, not the daughter, has automatic authority to override the directive

Answer and rationale — Question 5

Correct answer:

The applicable directive and current order record the client's decision for this situation. The nurse follows them, promptly informs the provider, and supports the distressed family through appropriate channels rather than resolving the conflict alone at the bedside.

Why the other choices do not fit:

A. Family preference does not override a valid directive.
B. A signature from a family member cannot authorize care the client has already refused.
D. A spouse does not have authority to override this applicable decision merely by being married to the client. Surrogate designation and default-surrogate rules vary by jurisdiction.

Teaching point. Honor the applicable decision and orders while continuing permitted treatment and support. A capable client's current wishes take precedence over an earlier advance directive.

Management of Care · RN26-A-005

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: AMA Code of Medical Ethics: Advance Directives — Opinion 5.2

Question 6

Classify each nursing action as protecting client confidentiality or not protecting client confidentiality.

Choose one classification for each row: Protects confidentiality · Does not protect confidentiality.

Finding or action	Your classification
Logging off the workstation before leaving the nurses' station	________
Casually discussing an identifiable client's laboratory results with a colleague in a public elevator where visitors can hear	________
Sharing an electronic health record password with a float nurse who forgot theirs	________
Giving handoff report in a location where it cannot be overheard by visitors	________
Opening the chart of a coworker on another unit out of personal concern, without an authorized work-related reason	________

Answer and rationale — Question 6

Correct answer:

Logging off the workstation before leaving the nurses' station: Protects confidentiality
Casually discussing an identifiable client's laboratory results with a colleague in a public elevator where visitors can hear: Does not protect confidentiality
Sharing an electronic health record password with a float nurse who forgot theirs: Does not protect confidentiality
Giving handoff report in a location where it cannot be overheard by visitors: Protects confidentiality
Opening the chart of a coworker on another unit out of personal concern, without an authorized work-related reason: Does not protect confidentiality

Authorized access and disclosure can include treatment, payment, health care operations, and other legally permitted purposes. Logging off and a private handoff protect information. Casual identifiable conversation in a public elevator, sharing credentials, and curiosity access lack appropriate safeguards or authorization.

Teaching point. Ask whether access is authorized for the work being performed and whether reasonable safeguards are in place. An incidental overheard fragment of a properly safeguarded care discussion is not automatically a HIPAA violation.

Management of Care · RN26-A-006

Castleport practice scoring: One point per correctly classified row. Maximum: 5 practice points.

Source: HHS: Summary of the HIPAA Privacy Rule — Permitted uses and disclosures; incidental use/disclosure; safeguards

Question 7

A registered nurse is supervising a newly licensed nurse who is about to start a transfusion of packed red blood cells. The new nurse has primed the tubing with 0.9% sodium chloride and is preparing to spike the unit alone. Which action should the supervising nurse take first? Facility policy requires a bedside check by two qualified staff members before starting the unit, and that check has not been completed.

A. Allow the transfusion to begin and check the documentation afterward
B. Stop the new nurse and complete the two-person verification of the unit and the client's identity
C. Tell the new nurse to replace the 0.9% sodium chloride with lactated Ringer's
D. Document the event as a near miss and continue

Answer and rationale — Question 7

Correct answer:

Stop before starting the unit and complete the bedside verification required by the stated facility policy. The intended recipient and blood container must be properly identified before transfusion. Priming with 0.9% sodium chloride is correct, so that part needs no change.

Why the other choices do not fit:

A. Verification after the fact cannot prevent an incompatible transfusion.
C. Lactated Ringer's contains calcium and should not share tubing with citrated blood components. The new nurse already chose an appropriate fluid.
D. Documenting is appropriate later. It does not stop the immediate risk.

Teaching point. Supervision means intervening before the error, not writing it up afterward.

Management of Care · RN26-A-007

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: AABB and partner organizations: Circular of Information for the Use of Human Blood and Blood Components — Printed p. 3: recipient/component identification, compatible solutions and early observation

Question 8

A client who lives alone is being discharged after a stroke with residual left-sided weakness. The client can walk short distances with a cane but cannot manage bathing and dressing independently. Which referral is most appropriate?

A. Physical therapy
B. Occupational therapy
C. Speech-language pathology
D. Respiratory therapy

Answer and rationale — Question 8

Correct answer:

Occupational therapy addresses activities of daily living: bathing, dressing, grooming, eating, and the adaptive equipment that makes them possible at home.

Why the other choices do not fit:

A. Physical therapy addresses gait, strength, balance, and mobility and may still be useful. Occupational therapy most directly addresses the stated bathing and dressing problem.
C. Speech-language pathology addresses communication and swallowing, neither of which is described here.
D. Nothing in this scenario involves airway clearance or oxygenation.

Teaching point. Match the referral to the unmet task. Occupational therapy is the best fit here for bathing, dressing, and adaptive equipment; other rehabilitation referrals may also be needed.

Management of Care · RN26-A-008

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: American Occupational Therapy Association: What Is Occupational Therapy? — Daily activities and examples including bathing/dressing/adaptive equipment

Question 9

A nurse discovers that a stable, awake client has swallowed one oral dose of the wrong medication. The administration is complete, and the client is breathing normally. Which action should the nurse take first?

A. Assess the client and the potential effects of the medication received
B. Complete the facility's internal occurrence report
C. Finish routine rounds before telling anyone
D. Document that the correct medication was given

Answer and rationale — Question 9

Correct answer:

The client comes first. Promptly assess for effects of the medication, obtain assistance and notify the responsible clinician, and carry out the response directed by the findings and medication involved. Record the facts accurately and complete the separate safety-reporting process.

Why the other choices do not fit:

B. Safety reporting matters, but it does not replace immediate assessment and clinical response.
C. Waiting could delay recognition and treatment of harm.
D. The record must accurately describe what was administered and the client's response.

Teaching point. A completed administration error requires prompt assessment, appropriate treatment, honest documentation, and reporting—not concealment or a universal paperwork sequence.

Management of Care · RN26-A-009

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: Open RN: Basic Concepts of Administering Medications — Medication rights, patient identification and medication safety

Question 10

Which client requires placement in an airborne infection isolation room?

A. A client with suspected pulmonary tuberculosis
B. A client with pertussis
C. A client with Clostridioides difficile infection
D. An infant with respiratory syncytial virus infection

Answer and rationale — Question 10

Correct answer:

Tuberculosis spreads by droplet nuclei that stay suspended in air, so it requires a negative-pressure airborne infection isolation room and a fit-tested respirator.

Why the other choices do not fit:

B. Pertussis requires droplet precautions, which do not require negative pressure.
C. C. difficile requires contact precautions and appropriate environmental disinfection. Hand-hygiene choice depends on visible soiling and outbreak or facility instructions; routine care does not universally exclude alcohol hand rub.
D. CDC lists contact plus standard precautions for RSV in infants and young children; additional precautions may be required by facility policy.

Teaching point. Airborne means negative pressure and a respirator. The short list to know cold is tuberculosis, measles, and varicella.

Safety and Infection Prevention and Control · RN26-A-010

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: CDC: Appendix A—Type and Duration of Precautions — Disease rows: suspected pulmonary/laryngeal tuberculosis, pertussis, RSV in infants/young children, C. difficile

Question 11

During a C. difficile outbreak, a nurse cares for a client with suspected infection and no other indication for respiratory isolation. Facility outbreak policy requires soap-and-water handwashing after care. Classify each action as indicated or not indicated.

Choose one classification for each row: Indicated · Not indicated.

Finding or action	Your classification
Place the client in a single room on contact precautions	________
Perform hand hygiene with soap and water after removing gloves	________
Use alcohol-based hand rub alone instead of the soap-and-water handwashing required by this outbreak policy	________
Clean the room with an EPA-registered sporicidal disinfectant	________
Wear a fit-tested N95 respirator to enter the room	________

Answer and rationale — Question 11

Correct answer:

Place the client in a single room on contact precautions: Indicated
Perform hand hygiene with soap and water after removing gloves: Indicated
Use alcohol-based hand rub alone instead of the soap-and-water handwashing required by this outbreak policy: Not indicated
Clean the room with an EPA-registered sporicidal disinfectant: Indicated
Wear a fit-tested N95 respirator to enter the room: Not indicated

Contact precautions and a sporicidal environmental disinfectant address C. difficile transmission. In this outbreak, the stated policy requires soap and water after care. CDC generally prefers alcohol-based hand rub for routine clinical hand hygiene when hands are not visibly soiled, including routine C. difficile care, while encouraging soap and water during outbreaks.

Teaching point. Do not turn the outbreak rule into a universal ban on alcohol hand rub. Gloves, gown, correct removal, hand hygiene, and appropriate environmental cleaning work together.

Safety and Infection Prevention and Control · RN26-A-011

Castleport practice scoring: One point per correctly classified row. Maximum: 5 practice points.

Source: CDC: Appendix A—Type and Duration of Precautions — Disease rows: suspected pulmonary/laryngeal tuberculosis, pertussis, RSV in infants/young children, C. difficile

Source: CDC: Clinical Safety—Hand Hygiene for Healthcare Workers — Key points; handwashing indications; C. difficile recommendations

Source: CDC: Clinical Guidance for C. difficile Infection Prevention — Isolation/contact precautions and environmental cleaning

Question 12

A nurse enters a room and finds a client lying on the floor beside the bed. The scene is safe, and the client is awake and says, 'I just slid down.' The client is breathing normally. Which action should the nurse take first?

A. Help the client back into bed
B. Assess the client for injury and check level of consciousness and vital signs
C. Call the client's family
D. Complete the occurrence report

Answer and rationale — Question 12

Correct answer:

Moving a client who may have a fracture, a head injury, or a new neurologic deficit can make the injury worse. Assessment comes before movement.

Why the other choices do not fit:

A. Lifting first risks compounding an undetected injury.
C. Family notification follows assessment and provider notification.
D. Reports are completed after the client is assessed and stabilized.

Teaching point. After a fall, assess before you lift. The client being awake and talking does not rule out injury.

Safety and Infection Prevention and Control · Take action · RN26-A-012

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: NHS: Falls — What to do if you fall; immediate-action injury concerns

Question 13

Which principles apply when a nurse sets up and maintains a sterile field? Select all that apply.

A. Only sterile items are placed on the sterile field.
B. The sterile field is kept at or above waist level and within the nurse's view.
C. The outer 1 inch (2.5 cm) border of the field is considered contaminated.
D. Reaching across the field with a nonsterile sleeve is acceptable as long as nothing is touched.
E. Moisture wicking through the drape from a nonsterile surface contaminates the field.

Answer and rationale — Question 13

Correct answer:

A, B, C, E

Sterility depends on what is on the field, where the field is, which parts of it count as sterile, and whether moisture has wicked through from a nonsterile surface.

Why the other choices do not fit:

D. A nonsterile sleeve should not pass over the sterile field even without contact; skin and clothing can shed particles onto it.

Teaching point. Sterile fields are lost to gravity, moisture, and things passing overhead, not only to touch.

Safety and Infection Prevention and Control · RN26-A-013

Castleport practice scoring: Add one per correct selection; subtract one per incorrect selection; minimum zero. Maximum: 4 practice points.

Source: Open RN: Aseptic Technique — Chapter 4, sterile-field principles: boundaries, visibility, moisture and contamination

Question 14

A hospitalized adult has a current order for a nonviolent wrist restraint because less restrictive measures failed to prevent immediate harm. Which observation shows appropriate ongoing restraint care?

A. The nurse checks safety and basic needs and discontinues the restraint as soon as the unsafe situation resolves
B. The restraint remains in use until the end of the shift because it is already ordered
C. The restraint is tightened to discourage the client from asking to move
D. The restraint is used mainly because staffing is short

Answer and rationale — Question 14

Correct answer:

A restraint is used only to protect immediate physical safety, under applicable requirements, and must be discontinued at the earliest possible time. An order does not remove the need for ongoing monitoring or permit convenience use.

Why the other choices do not fit:

B. A restraint is not continued for an arbitrary shift length after the safety need has ended.
C. Restraints must not be used for punishment or coercion; circulation, skin, comfort, and basic needs require monitoring.
D. Staff convenience or inadequate staffing is not a valid reason for restraint.

Teaching point. The safety need—not the shift clock or staff convenience—determines whether a restraint remains necessary.

Safety and Infection Prevention and Control · RN26-A-014

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: CMS: State Operations Manual, Appendix A—Hospitals — Tag A-0154, 42 CFR 482.13(e),

Question 15

Before administering a medication, which combination should the nurse use to identify the client?

A. Room number and bed number
B. The client's full name and date of birth
C. The client's full name and room number
D. The name on the door and the client's diagnosis

Answer and rationale — Question 15

Correct answer:

Two client-specific identifiers are required, and neither one may be the client's location. Name plus date of birth, or name plus medical record number, meets that standard.

Why the other choices do not fit:

A. Location is never an acceptable identifier because clients move.
C. The room number half of this answer disqualifies it.
D. A diagnosis is not unique to a client and a door sign is not an identifier.

Teaching point. Two identifiers, neither of them where the client happens to be lying.

Safety and Infection Prevention and Control · RN26-A-015

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: Open RN: Basic Concepts of Administering Medications — Medication rights, patient identification and medication safety

Question 16

Facility fire policy uses RACE: Rescue, Alarm, Contain, Extinguish/Evacuate. A nurse discovers a small fire, moves the only client in immediate danger to safety, and confirms that no one has raised the alarm. Under this plan, what should the nurse do next?

A. Attempt to extinguish the fire
B. Activate the fire alarm
C. Close doors and windows to contain the fire
D. Open the windows to clear the smoke

Answer and rationale — Question 16

Correct answer:

Rescue has been completed. Raising the alarm brings help and starts the facility response before this nurse attempts containment or a safe, trained response to the fire.

Why the other choices do not fit:

A. Do not delay the alarm to fight a fire. Extinguishing is only an option for a trained person with a safe exit; evacuation may be required.
C. Under the stated sequence, this nurse raises the alarm next; other team members may perform actions concurrently.
D. Opening windows is not the next action in the stated fire plan and delays raising the alarm.

Teaching point. Follow the emergency plan. Here, rescue is complete and the alarm has not yet been raised; extinguishing is attempted only when trained, safe, and appropriate.

Safety and Infection Prevention and Control · RN26-A-016

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: U.S. Fire Administration: Home Fire Escape Plans — Escape planning and prompt response to alarms

Question 17

A nurse is examining a 6-month-old infant at a well-child visit. Which finding requires further evaluation?

A. Rolls from tummy to back
B. Cannot hold the head steady without support when held upright
C. Reaches to grab a wanted toy
D. Sits briefly while propped forward on the hands

Answer and rationale — Question 17

Correct answer:

CDC lists holding the head steady without support when being held as a four-month milestone. A six-month-old who cannot do this needs developmental follow-up; the finding alone does not establish a diagnosis.

Why the other choices do not fit:

A. Rolling from tummy to back is on CDC's six-month milestone checklist.
C. Reaching to grab a wanted toy is on the six-month checklist.
D. Leaning on the hands to support sitting is on the six-month checklist.

Teaching point. Compare the observation with the relevant age milestone and arrange follow-up for a missed skill; one missed milestone is not a diagnosis.

Health Promotion and Maintenance · RN26-A-017

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: CDC: Milestones by 4 Months — Movement/physical development

Source: CDC: Milestones by 6 Months — Movement/physical development

Question 18

Two hours after a vaginal birth, a nurse finds that the client's fundus is boggy and 1 cm above the umbilicus at midline, with moderate lochia rubra. Vital signs are stable, and there is no brisk ongoing bleeding. Which action should the nurse take first?

A. Massage the fundus
B. Notify the provider
C. Increase the intravenous infusion rate
D. Document the finding and reassess in 30 minutes

Answer and rationale — Question 18

Correct answer:

A boggy uterus has poor tone and can bleed. Fundal massage is an immediate bedside intervention to encourage contraction while the nurse reassesses uterine tone and blood loss.

Why the other choices do not fit:

B. In this stable presentation, the nurse can begin massage immediately while reassessing. With brisk bleeding or instability, summon help at once and act concurrently.
C. An arbitrary fluid-rate increase does not replace assessment and uterine treatment; fluids and uterotonics require the appropriate orders or protocol.
D. Waiting 30 minutes with a boggy fundus allows blood loss to continue.

Teaching point. Massage a boggy fundus and reassess promptly. Heavy or increasing bleeding, instability, or persistent poor tone requires immediate help and the postpartum-hemorrhage response—not a wait-and-see interval.

Health Promotion and Maintenance · RN26-A-018

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: RCOG: Heavy Bleeding After Birth (Postpartum Haemorrhage) — What happens if I have a primary PPH?—uterine massage and additional treatment

Question 19

A client at 34 weeks' gestation is seen in the clinic. Select the 3 findings that require immediate follow-up.

A. Blood pressure 152/98 mm Hg
B. Headache that has not responded to acetaminophen
C. Right upper quadrant and epigastric pain
D. Mild positional lower back ache after standing that resolves with rest, without bleeding, fluid leakage, or regular contractions
E. Occasional irregular tightening that stops with rest, without bleeding or fluid leakage

Answer and rationale — Question 19

Correct answer:

A, B, C

Hypertension after 20 weeks, a persistent headache, and right upper quadrant or epigastric pain raise concern for preeclampsia and need immediate clinical assessment. One reading and these symptoms do not by themselves confirm the diagnosis.

Why the other choices do not fit:

D. This isolated, resolving positional discomfort is less concerning than the three selected findings; persistent or new symptoms still need assessment.
E. The described resolving, irregular tightening is less concerning than the selected findings. Persistent, regular, or associated warning symptoms would change that assessment.

Teaching point. Persistent headache and upper abdominal pain in late pregnancy deserve urgent assessment. Do not wait for the blood pressure to reach severe range.

Health Promotion and Maintenance · RN26-A-019

Castleport practice scoring: Select exactly the stated number; one point per correct selection. Maximum: 3 practice points.

Source: NHLBI: Pregnancy and High Blood Pressure — Types of high blood pressure disorders; warning symptoms

Source: CDC: Urgent Maternal Warning Signs and Symptoms — Headache that will not go away; severe belly pain

Question 20

A nurse is teaching a 68-year-old client about fall prevention at home. Which statement indicates a need for further teaching?

A. 'I keep a small throw rug beside my bed so my feet do not touch a cold floor.'
B. 'I had my vision checked this year and got new glasses.'
C. 'I put a night light in the hallway between my bedroom and the bathroom.'
D. 'I asked the pharmacist to review all my medicines for ones that make me dizzy.'

Answer and rationale — Question 20

Correct answer:

Loose throw rugs are a trip hazard. The other three statements describe fall-prevention measures recommended in CDC materials: vision care, adequate lighting, and medication review.

Why the other choices do not fit:

B. Correcting vision reduces fall risk.
C. Lighting the nighttime path to the bathroom reduces falls.
D. Reviewing medications that cause dizziness or sedation is a core fall-prevention strategy.

Teaching point. With a 'needs further teaching' stem, look for the one statement that describes a hazard the client is proud of.

Health Promotion and Maintenance · RN26-A-020

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: CDC STEADI: What YOU Can Do to Prevent Falls — Prevention advice

Question 21

A 15-year-old comes to the clinic for a sports physical with a parent. Which approach best supports a useful health screening?

A. Interview the adolescent with the parent present throughout to keep the history accurate
B. Explain confidentiality and its limits, then spend part of the visit interviewing the adolescent alone
C. Ask the parent to complete the history form and skip questions about risk behaviors
D. Tell the adolescent that nothing discussed will ever be shared with anyone

Answer and rationale — Question 21

Correct answer:

Private time can support a more candid health discussion and developing independence. Explain confidentiality and its legal and safety limits before asking sensitive questions.

Why the other choices do not fit:

A. Keeping a parent present for the entire interview can make some sensitive disclosures harder and removes the routine opportunity for private discussion.
C. Skipping risk screening removes the main reason to do the interview.
D. Promising unlimited confidentiality is untrue. Mandatory reporting and safety concerns are exceptions, and the adolescent deserves to know that before speaking.

Teaching point. Say what is confidential and what is not before you ask the question, not after you hear the answer.

Health Promotion and Maintenance · RN26-A-021

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: AAP: Confidentiality in the Care of Adolescents—Policy Statement — Recommendations on routine private time and limits of confidentiality

Question 22

A client newly diagnosed with cancer says, 'I do not really see the point of going through treatment.' Which response by the nurse is most therapeutic?

A. 'Tell me more about what you are thinking.'
B. 'You should not talk that way. Many people do very well with treatment.'
C. 'Have you told your family how you feel about this?'
D. 'Let us talk about something more positive for a few minutes.'

Answer and rationale — Question 22

Correct answer:

An open invitation keeps the client talking and lets the nurse learn what is behind the statement, which could be fear, exhaustion, a misunderstanding of the prognosis, or low mood that needs assessment.

Why the other choices do not fit:

B. Telling a client not to feel what they feel ends the conversation and adds shame.
C. Redirecting to the family moves attention away from the client who just opened a difficult door.
D. Changing the subject is avoidance.

Teaching point. Start by understanding this client's meaning rather than correcting or redirecting it. A stated intention to self-harm or another immediate danger would require direct safety assessment.

Psychosocial Integrity · RN26-A-022

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: NCI: Communication in Cancer Care—Health Professional PDQ — Responding to emotion and supportive clinician communication

Question 23

A client whose spouse died three weeks ago tells the home health nurse, 'I still set two places at the table every night.' Which response is most appropriate?

A. 'That sounds like a way of keeping your spouse close. What has that been like for you?'
B. 'It has been three weeks. You need to start letting go.'
C. 'That is a sign of complicated grief and I will refer you for evaluation.'
D. 'At least you had many years together.'

Answer and rationale — Question 23

Correct answer:

Setting two places three weeks after a death does not by itself establish a grief disorder. Acknowledging the behavior and inviting the client to describe it supports coping and gives the nurse real information about how the client is doing.

Why the other choices do not fit:

B. Grief has no schedule, and telling someone to move on is not therapeutic.
C. Diagnosing a grief disorder from this behavior alone is premature. That does not mean counseling or other support is inappropriate when needed or requested.
D. Silver linings minimize the loss.

Teaching point. Listen without imposing a timetable. Assess functioning and safety, and offer support or referral when the client needs or wants it—not only when a calendar threshold is reached.

Psychosocial Integrity · RN26-A-023

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: NCI: Grief, Bereavement, and Coping With Loss — Normal grief and variation; difficulties requiring assessment

Question 24

An older adult hospitalized with pneumonia becomes confused on the second day. Which findings suggest delirium rather than dementia? Select all that apply.

A. Onset over hours to days
B. Level of consciousness that fluctuates through the day
C. Gradual decline in memory over the past two years
D. Marked difficulty sustaining attention
E. New confusion developed during this acute pneumonia illness rather than as a gradual decline over years

Answer and rationale — Question 24

Correct answer:

A, B, D, E

Delirium commonly begins acutely, fluctuates, and affects attention. Acute infection can contribute, and assessment must also consider medications, hypoxia, pain, dehydration, withdrawal, and other causes. Addressing the cause and supporting safety are central to care.

Why the other choices do not fit:

C. A slow decline over years describes dementia, which can coexist with delirium but is not the acute change.

Teaching point. Acute change, fluctuating awareness, and inattention warrant delirium assessment. Treat the cause and use supportive measures; severe distress or danger may require additional prescribed treatment.

Psychosocial Integrity · RN26-A-024

Castleport practice scoring: Add one per correct selection; subtract one per incorrect selection; minimum zero. Maximum: 4 practice points.

Source: NIH/NLM MedlinePlus: Delirium — Symptoms, causes and treatment

Question 25

On a behavioral health unit, a client is pacing the hallway, speaking loudly, and clenching both fists. Which action should the nurse take first? The client has no weapon, has not attempted an assault, and trained staff support is available.

A. Approach calmly at a safe distance with a clear path to the exit, speak in short simple sentences, and offer a quieter space
B. Take the client by the arm and guide them to their room
C. Call security to the unit immediately and wait in the nurses' station
D. Ignore the behavior so it is not reinforced

Answer and rationale — Question 25

Correct answer:

Calm verbal de-escalation, personal space, and a clear exit are appropriate early responses when it is safe to engage. Obtain staff support as needed and reassess for immediate danger rather than assuming conversation will always work.

Why the other choices do not fit:

B. Touching an agitated client without warning often triggers the very escalation you are trying to prevent.
C. Calling for support can be appropriate and can occur while a safe de-escalation attempt begins. Simply waiting elsewhere does not address the client's current distress.
D. Ignoring agitation does not extinguish it and misses a client in distress.

Teaching point. Use space, a calm voice, short sentences, and a safe exit. Escalate the safety response when the level of danger requires it.

Psychosocial Integrity · RN26-A-025

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: AAEP Project BETA: Verbal De-escalation of the Agitated Patient — Ten domains, especially I-IV: personal space, exits, nonprovocation and concise speech

Question 26

During a home visit, a nurse notes that an older adult client has multiple unexplained bruises. The adult child who lives with the client answers every question directed at the client and stays in the room. Which action should the nurse take?

A. Document the bruises and plan to watch for changes at the next visit
B. Ask the adult child to explain how each bruise happened
C. Arrange to interview the client alone and report the suspected abuse as required by law
D. Tell the adult child that the bruises will have to be reported to the authorities

Answer and rationale — Question 26

Correct answer:

Unexplained bruising and a caregiver controlling the conversation warrant concern and a private, safe assessment. Document objective findings and follow applicable reporting law and safeguarding procedures; suspicion should not be ignored while waiting for proof. Bruise color does not reliably establish the age of an injury.

Why the other choices do not fit:

A. Waiting leaves a client in a potentially unsafe situation.
B. Asking the possible abuser to narrate the injuries is unreliable and may increase risk to the client.
D. Announcing the report to the person under suspicion can put the client in danger.

Teaching point. Prioritize immediate safety, seek a private assessment when safe, document objectively, and follow the jurisdiction's reporting requirements.

Psychosocial Integrity · RN26-A-026

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: NIA: Elder Abuse — Signs of abuse and getting help

Question 27

A client with dysphagia after a stroke is about to eat lunch. Which action best reduces the risk of aspiration? A swallowing assessment and individualized feeding plan are documented.

A. Position the client upright as tolerated and follow the documented swallowing plan for food texture, liquids, assistance, and any prescribed posture
B. Offer thin liquids through a straw to make swallowing easier
C. Encourage the client to eat quickly while energy is good
D. Lay the client back at 30 degrees to slow the passage of food

Answer and rationale — Question 27

Correct answer:

An upright position and the individualized swallowing plan reduce avoidable risk. Postures such as chin tuck, texture changes, and the use or avoidance of straws depend on the swallowing problem and assessment; they are not blanket rules for every client with stroke.

Why the other choices do not fit:

B. Do not substitute thin liquids or a straw for the assessed plan. Their safety varies with the client's swallowing impairment.
C. Rushing increases the chance of a poorly controlled swallow.
D. Reclining is not the planned upright feeding position and can increase aspiration risk in this situation.

Teaching point. Use the assessed swallowing plan, appropriate positioning, and an unhurried pace. Do not add a chin tuck or change liquid consistency without the indicated plan.

Basic Care and Comfort · RN26-A-027

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: ASHA: Adult Dysphagia — Assessment, individualized treatment and postural techniques

Question 28

A nurse assessing an immobile client finds an area of intact skin over the sacrum with redness that does not blanch when pressed. How should the nurse classify this finding?

A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Deep tissue pressure injury
D. Unstageable pressure injury

Answer and rationale — Question 28

Correct answer:

Intact skin with non-blanchable erythema is the definition of a stage 1 pressure injury. The skin is unbroken, and the redness persists under pressure because the tissue underneath is already damaged.

Why the other choices do not fit:

B. Stage 2 involves partial-thickness skin loss with an exposed dermis, often looking like a shallow open ulcer or an intact or ruptured blister.
C. A deep tissue pressure injury shows persistent non-blanchable deep red, maroon, or purple discoloration, or a blood-filled blister.
D. Unstageable means the base of the wound is obscured by slough or eschar, which requires an open wound.

Teaching point. Stage the assessed pressure injury, not every skin lesion. Stage 1 has intact skin with non-blanchable erythema; a stage 2 injury may include an intact serum-filled blister.

Basic Care and Comfort · RN26-A-028

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: NPIAP: Pressure Injury Staging Poster — PDF page 1, stages 1-4,

Question 29

A nurse is preparing to give an intermittent feeding through a client's nasogastric tube. Which action should the nurse take before starting the feeding? Initial radiographic placement has already been confirmed, and there is no contraindication to head elevation.

A. Warm the formula in a microwave until it is hot to the touch
B. Verify continued tube placement using the validated method required by facility policy and raise the head of the bed 30-45 degrees
C. Lay the client flat so the formula does not run in too quickly
D. Flush the tube with sterile water only if the client reports nausea

Answer and rationale — Question 29

Correct answer:

Feeding into a misplaced tube and aspiration of refluxed formula can cause serious harm. Confirm continued placement according to the validated facility process and maintain head elevation of 30-45 degrees unless contraindicated before delivering formula.

Why the other choices do not fit:

A. Hot formula is not an appropriate preparation for this feeding. Use the prescribed preparation and temperature, not a microwave-until-hot instruction.
C. Lying flat during a feeding increases the risk of reflux and aspiration.
D. Nausea is not the criterion for deciding whether to flush. Follow the prescribed flushing schedule and assess any intolerance before continuing feeding.

Teaching point. Confirm placement and appropriate positioning before feeding. An external length mark helps detect migration but is not sufficient proof of safe placement on its own.

Basic Care and Comfort · RN26-A-029

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: Open RN: Enteral Tube Management — 17.2: Assessing Tube Placement; Reducing Risk of Aspiration

Question 30

A nurse has assessed a client with right-sided weakness as able to bear weight and complete a one-person stand-pivot transfer using a gait belt. The client follows instructions, wears nonslip footwear, and has no contraindication to the belt. Place these actions in order. The individualized mobility plan specifies transfer toward the stronger left side.

Write the step labels in the correct order.

S3. Have the client push from the bed and stand on a coordinated count while the nurse supports the transfer with the belt
S1. Lock the bed and chair wheels, set the bed height so the client can place both feet on the floor, and position the chair on the stronger left side
S4. Pivot toward the chair and lower the client into the seat
S2. Assist the client to sit on the edge of the bed, check for dizziness, and apply the gait belt securely

Answer and rationale — Question 30

Correct answer:

S1 → S2 → S3 → S4

Lock the bed and chair wheels, set the bed height so the client can place both feet on the floor, and position the chair on the stronger left side
Assist the client to sit on the edge of the bed, check for dizziness, and apply the gait belt securely
Have the client push from the bed and stand on a coordinated count while the nurse supports the transfer with the belt
Pivot toward the chair and lower the client into the seat

Setting up the environment comes first. Sitting at the edge allows the nurse to check for dizziness before standing. The coordinated stand precedes the pivot and controlled lowering; stop and obtain more assistance if the client cannot safely perform the assessed transfer.

Teaching point. Chair on the strong side. Dangle before you stand. Hands on the bed, never around the nurse's neck.

Basic Care and Comfort · RN26-A-030

Castleport practice scoring: One point per step in its correct position. Maximum: 4 practice points.

Source: MedlinePlus: Moving a Patient From Bed to a Wheelchair — Preparation; Getting a Patient Ready to Transfer; Pivot Turn

Question 31

A client with advanced dementia cannot report pain verbally. Which finding most strongly suggests the client is experiencing pain?

A. Sleeping for several hours during the afternoon
B. Grimacing and guarding the left hip when being repositioned
C. Refusing a visitor
D. Asking the same question several times in an hour

Answer and rationale — Question 31

Correct answer:

In clients who cannot self-report, pain is assessed through observed behavior: facial expression, guarding, vocalization, body movement, and changes in activity, especially when they appear during movement of a specific body part.

Why the other choices do not fit:

A. Afternoon sleep is common and nonspecific.
C. Refusing a visitor may reflect fatigue, mood, or preference.
D. Repetitive questioning can reflect cognitive impairment or other distress; by itself it is less specific for pain than guarding and grimacing with hip movement.

Teaching point. When a client cannot tell you, watch the face and watch what happens when you move them. Use an appropriate observational pain tool and reassess the response to care; behavior alone does not establish the underlying cause.

Basic Care and Comfort · RN26-A-031

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: NCI: Cancer Pain—Health Professional PDQ — Pain Assessment > Special Considerations > Cognitive impairment

Question 32

A client is prescribed digoxin 0.125 mg orally daily. Which assessment should the nurse complete immediately before administering the dose? The prescription says to withhold the dose and notify the provider if the apical rate is below 60/min.

A. Blood pressure in both arms
B. Apical pulse for one full minute
C. Respiratory rate for 30 seconds
D. Capillary refill in the fingers

Answer and rationale — Question 32

Correct answer:

Digoxin can slow the heart rate. Auscultating the apical pulse for one full minute checks rate and rhythm before administration. In this question, a rate below 60/min triggers the expressly prescribed hold-and-notify instruction; use the actual prescription rather than a universal threshold.

Why the other choices do not fit:

A. Blood pressure is monitored, but heart rate is the parameter that determines whether this dose is given.
C. Respiratory rate is not a digoxin holding parameter.
D. Capillary refill does not guide digoxin administration.

Teaching point. Apical for a full minute, every dose. Bradycardia is the reason the parameter exists.

Pharmacological and Parenteral Therapies · RN26-A-032

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: OpenStax: Clinical Nursing Skills, Heart Rate — Apical pulse assessment and medication considerations

Source: Open RN: Basic Concepts of Administering Medications — Medication rights, patient identification and medication safety

Question 33

A prescription reads: heparin 25,000 units in 250 mL of 5% dextrose in water, infuse at 1,000 units/hr. At what rate in milliliters per hour should the nurse set the infusion pump? Record your answer as a whole number.

Your answer: ______ mL/hr

Answer and rationale — Question 33

Correct answer:

10 mL/hr

Concentration first: 25,000 units divided by 250 mL equals 100 units per mL. Then 1,000 units per hour divided by 100 units per mL equals 10 mL per hour.

Teaching point. Find the concentration before you find the rate. Two short steps beat one long formula, and they are easier to check. These are the supplied numbers for a calculation exercise, not a dosing recommendation.

Pharmacological and Parenteral Therapies · RN26-A-033

Castleport practice scoring: One point for the correct numeric answer in the stated unit. Maximum: 1 practice point.

Source: Open RN: Math Calculations — 5.6 Dimensional Analysis; infusion calculations

Question 34

A client with a gastrostomy tube has several medications listed. Which formulation must not be crushed because crushing defeats its controlled-release mechanism?

A. Acetaminophen 325 mg tablet
B. Metoprolol succinate extended-release tablet
C. Levothyroxine 75 mcg tablet
D. Lisinopril 10 mg tablet

Answer and rationale — Question 34

Correct answer:

Crushing an extended-release tablet can defeat controlled release and expose the client to an unsafe dose. Do not crush it. The pharmacist and prescriber should identify a suitable formulation and dose for the route; an alternative is not automatically interchangeable.

Why the other choices do not fit:

A. This option is not identified as the extended-release formulation in the question. The exact product, route, and handling instructions still need checking before crushing or tube administration.
C. This option is not identified as the extended-release formulation in the question. The exact product, route, and handling instructions still need checking before crushing or tube administration.
D. This option is not identified as the extended-release formulation in the question. The exact product, route, and handling instructions still need checking before crushing or tube administration.

Teaching point. If the name carries ER, XL, XR, SR, CD, or enteric-coated, stop and check before you crush it.

Pharmacological and Parenteral Therapies · RN26-A-034

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: ASHP Patient Medication Information: Metoprolol — How should this medicine be used?—extended-release tablets

Question 35

A client is receiving intravenous vancomycin. Complete the sentence by choosing the correct option for each blank.

The nurse should monitor the client's ______ — choose from: serum creatinine; serum amylase; serum bilirubin
because vancomycin is associated with ______ — choose from: nephrotoxicity; hyperkalemia; polycythemia

Answer and rationale — Question 35

Correct answer:

serum creatinine; nephrotoxicity

Vancomycin is cleared by the kidneys and is associated with nephrotoxicity, particularly at higher exposures and with other nephrotoxic drugs. Serum creatinine is the routine monitor, along with drug levels and urine output. Amylase and bilirubin are not the renal-function measure asked for here; hyperkalemia and polycythemia do not identify the medication-related kidney injury targeted by this question.

Teaching point. For this practice item, both blanks must be correct to earn the point. Read the medication-related risk and the monitoring choice together.

Pharmacological and Parenteral Therapies · RN26-A-035

Castleport practice scoring: One point only when all linked blanks are correct. Maximum: 1 practice point.

Source: Pfizer Medical: Vancomycin Injection—Warnings and Precautions — Acute Kidney Injury

Question 36

A client receiving intravenous potassium chloride through a peripheral line reports burning at the insertion site. Which action should the nurse take first?

A. Slow the infusion and continue to observe
B. Stop the infusion and assess the site
C. Apply a warm compress above the site
D. Administer a prescribed analgesic

Answer and rationale — Question 36

Correct answer:

Burning may mean vein irritation, but it may also mean infiltration or extravasation. Stopping removes the ongoing exposure, and assessing the site is what tells the nurse which problem this is.

Why the other choices do not fit:

A. Slowing an infusion that may be going into tissue continues the injury.
C. A compress may be appropriate later, after the cause is identified and per policy.
D. Medicating the symptom leaves the cause in place.

Teaching point. New infusion-site pain needs an immediate stop and assessment in this situation. Do not flush a suspected extravasation; follow the drug-specific protocol for further actions.

Pharmacological and Parenteral Therapies · RN26-A-036

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: Open RN: IV Therapy Management — Site assessment and IV complications; response to infiltration

Question 37

Which actions should the nurse take before starting a transfusion of packed red blood cells? Select all that apply. Facility policy requires bedside verification by two qualified staff members, close observation for the first 15 minutes, and an initially slow rate.

A. Verify the prescription, the blood product, and the client's identity with a second qualified person
B. Prime the administration set with 0.9% sodium chloride
C. Obtain a baseline set of vital signs
D. Prime the administration set with lactated Ringer's
E. Plan to remain with the client for the first 15 minutes of the transfusion

Answer and rationale — Question 37

Correct answer:

A, B, C, E

The stated policy requires two-person bedside verification. Baseline vital signs make a later change interpretable. Serious reactions can occur after a small volume, so begin slowly and observe closely. Use compatible tubing and solutions according to the blood-component instructions and facility policy.

Why the other choices do not fit:

D. Lactated Ringer's contains calcium and should not share tubing with citrated blood. AABB permits 0.9% sodium chloride and recognizes specific other solutions only when FDA-approved for this use or documented compatible; it does not say saline is the only possible compatible solution.

Teaching point. Verify the recipient and unit, record baseline observations, use compatible equipment and fluid, and watch closely at the start. Stop the transfusion and obtain help if a reaction is suspected.

Pharmacological and Parenteral Therapies · RN26-A-037

Castleport practice scoring: Add one per correct selection; subtract one per incorrect selection; minimum zero. Maximum: 4 practice points.

Question 38

A client using a morphine patient-controlled analgesia pump has a respiratory rate of 7/min and is difficult to rouse. Which action should the nurse take first? A definite pulse is present.

A. Stop the PCA, activate the emergency response, support the airway and assist ventilation as needed, and give naloxone under the emergency protocol
B. Document the findings and recheck in 15 minutes
C. Reduce the pump's demand dose and continue the infusion
D. Wait for the provider to arrive before taking action

Answer and rationale — Question 38

Correct answer:

Stop opioid delivery, activate urgent help, and support the airway and ventilation immediately. Give naloxone according to the standing order or emergency protocol without waiting for another clinician to arrive. Oxygen alone does not correct inadequate ventilation.

Why the other choices do not fit:

B. A respiratory rate of 7 with sedation is an emergency, not something to recheck later.
C. Reducing the dose still delivers opioid to a client who is already over-sedated.
D. Waiting delays airway and breathing support.

Teaching point. A client who is hard to wake and breathing seven times per minute after an opioid needs an emergency response. Support breathing while reversing the opioid effect.

Pharmacological and Parenteral Therapies · RN26-A-038

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: AHA: Adult and Pediatric Special Circumstances of Resuscitation — 21.11 Opioids: respiratory depression with a definite pulse; naloxone and recurrence monitoring

Question 39

A client is receiving a continuous intravenous heparin infusion. Highlight each finding in the note that requires follow-up before the infusion continues.

Select every finding that answers the question.

H1. Activated partial thromboplastin time 110 seconds (facility therapeutic range 60 to 80 seconds).
H2. Platelet count 92,000/mm3, was 248,000/mm3 before heparin began six days ago.
H3. Client reports one black, tarry stool this morning.
H4. Blood pressure 118/70 mm Hg.
H5. Heart rate 78/min and regular.
H6. Reports incisional discomfort rated 2 on a 0-to-10 scale.

Answer and rationale — Question 39

Correct answer:

Activated partial thromboplastin time 110 seconds (facility therapeutic range 60 to 80 seconds).
Platelet count 92,000/mm3, was 248,000/mm3 before heparin began six days ago.
Client reports one black, tarry stool this morning.

The aPTT exceeds the supplied therapeutic range, the platelet count has fallen by more than half during a compatible heparin-exposure interval, and black tarry stool suggests gastrointestinal bleeding. Stop the infusion under the safety protocol and obtain urgent clinical review. The platelet fall raises concern for HIT but does not diagnose it; other causes and the complete clinical score require assessment.

Teaching point. On plus/minus scoring, highlighting a normal blood pressure costs you a point you already earned. Select only what you can defend.

Pharmacological and Parenteral Therapies · RN26-A-039

Castleport practice scoring: Add one per correct selection; subtract one per incorrect selection; minimum zero. Maximum: 3 practice points.

Source: ASH: Diagnosis and Management of Heparin-Induced Thrombocytopenia Pocket Guide — 4Ts table,

Question 40

Two hours after an adult client's cardiac catheterization through the right femoral artery, which finding requires immediate action?

A. The right foot is cool and the right pedal pulse is not palpable
B. A small amount of dried blood is present on the dressing edge
C. The client reports mild discomfort at the insertion site
D. Urine output has been 60 mL/hr since the procedure

Answer and rationale — Question 40

Correct answer:

A cool extremity with an absent pulse distal to an arterial access site suggests obstruction of blood flow, which can cost the limb if it is not addressed quickly.

Why the other choices do not fit:

B. A small amount of dried blood is common. Active or expanding bleeding is not.
C. Mild site discomfort is expected. Severe or increasing pain would not be.
D. 60 mL/hr is not the urgent limb-perfusion finding described here. Continue renal monitoring; one urine-output value does not exclude kidney injury.

Teaching point. After any arterial procedure, compare the two limbs. Color, temperature, pulse, movement, and sensation.

Reduction of Risk Potential · RN26-A-040

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: NHLBI: Recovering From Cardiac Catheterization — When to call the doctor

Question 41

A client is two days post-operative after a total knee replacement. Highlight each finding in the note that suggests a possible deep vein thrombosis.

Select every finding that answers the question.

H1. Left calf is swollen compared with the right, measuring 3 cm larger in circumference.
H2. Left calf is warm to the touch with new redness along the posterior aspect.
H3. Client reports left calf pain that worsens when walking.
H4. Surgical incision is clean, dry, and intact with staples in place.
H5. Temperature 37.1 C (98.8 F).
H6. Ambulated in the hallway twice with a walker today.

Answer and rationale — Question 41

Correct answer:

Left calf is swollen compared with the right, measuring 3 cm larger in circumference.
Left calf is warm to the touch with new redness along the posterior aspect.
Client reports left calf pain that worsens when walking.

Unilateral swelling, warmth, redness, and calf pain in a post-operative client with reduced mobility are the classic cues for deep vein thrombosis. The comparison with the other leg is what makes the swelling meaningful.

Teaching point. New asymmetric swelling, warmth, and pain warrant prompt DVT assessment. Bilateral swelling does not exclude thrombosis, and symptoms alone do not confirm it.

Reduction of Risk Potential · Recognize cues · RN26-A-041

Castleport practice scoring: Add one per correct selection; subtract one per incorrect selection; minimum zero. Maximum: 3 practice points.

Source: CDC: About Venous Thromboembolism — Signs and symptoms; diagnosis

Question 42

An adult client takes lisinopril daily. Using the laboratory reference intervals shown, which result should the nurse report before the next dose is given?

A. Sodium 138 mEq/L (reference 135-145)
B. Potassium 5.9 mEq/L (reference 3.5-5.0)
C. Hemoglobin 13.2 g/dL (this laboratory's reference 12.0-15.5)
D. White blood cell count 7,800/mm3 (reference 4,500-11,000)

Answer and rationale — Question 42

Correct answer:

ACE inhibitors reduce aldosterone and cause potassium retention. A potassium of 5.9 mEq/L is above the usual reference range and carries a risk of cardiac dysrhythmia, so the provider decides before another dose is given.

Why the other choices do not fit:

A. 138 mEq/L is within the usual reference range.
C. 13.2 g/dL is within the laboratory interval supplied for this client.
D. 7,800/mm3 is within the usual reference range.

Teaching point. Connect the medication to its monitored risks. An elevated potassium in a client taking an ACE inhibitor needs prompt review.

Reduction of Risk Potential · RN26-A-042

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: KDIGO Conference Report: Acute Hyperkalemia in the Emergency Department — Medication contributors and ECG changes, printed pp. 331-333

Question 43

A blindly inserted nasogastric tube has just been inserted for intermittent feedings. Select the 3 actions the nurse should take before the first feeding is started.

A. Obtain the radiographic confirmation of tube position ordered for initial placement
B. Mark and document the length of tube exiting the nare
C. Document the insertion, the client's tolerance, and the confirmed position
D. Before position is confirmed, instill 60 mL of water to check for obstruction
E. Inject air into the tube and confirm placement by auscultation alone

Answer and rationale — Question 43

Correct answer:

A, B, C

Radiographic confirmation is the standard for initial placement of a blindly inserted feeding tube. Marking the exit length gives every later shift a reference point for detecting migration, and documentation makes both available to the next nurse.

Why the other choices do not fit:

D. Instilling fluid before position is confirmed can deliver it into the lung.
E. Auscultation of an air bolus is unreliable and is not an acceptable sole method of confirming placement.

Teaching point. Confirm initial placement before using the tube. Record the external mark, then use the approved ongoing placement-check process; the mark alone is not proof of safe position.

Reduction of Risk Potential · Generate solutions · RN26-A-043

Castleport practice scoring: Select exactly the stated number; one point per correct selection. Maximum: 3 practice points.

Source: Open RN: Enteral Tube Management — 17.2: Assessing Tube Placement; Reducing Risk of Aspiration

Question 44

A healthy adult is scheduled for elective surgery under general anesthesia in two hours. Which finding should the nurse report to the surgical team immediately? The anesthesia team instructed this client to have no solid food or milk after midnight; the current time is 0800.

A. The client ate a bowl of cereal with milk two hours ago
B. The client reports feeling nervous about the procedure
C. The client removed a wedding ring and gave it to a family member
D. The client voided 250 mL before the pre-operative medication

Answer and rationale — Question 44

Correct answer:

Recent oral intake before general anesthesia raises the risk of aspiration during induction. Only the anesthesia team can decide whether to delay or proceed, so this finding is reported at once.

Why the other choices do not fit:

B. Pre-operative anxiety is common and is addressed, not escalated as an emergency.
C. Removing jewelry is the expected pre-operative action.
D. Voiding before pre-operative medication is expected.

Teaching point. Report recent food intake and its exact timing before elective anesthesia. The anesthesia team assesses aspiration risk and the appropriate plan; do not independently promise that surgery will proceed or be canceled.

Reduction of Risk Potential · RN26-A-044

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: American Society of Anesthesiologists: Preparing for Surgery Checklist — Follow pre-surgery directions—food, drink and aspiration risk

Question 45

A client has a water-seal chest drainage system on prescribed suction. Respiratory status and drainage had been stable. Which new finding requires prompt assessment?

A. The water seal is at the manufacturer-specified level and the drainage unit remains below the chest
B. Fluid in the water seal chamber rising and falling with respiration
C. New continuous vigorous bubbling in the water seal chamber
D. 30 mL of serosanguineous drainage over the past four hours

Answer and rationale — Question 45

Correct answer:

New continuous bubbling in the water-seal chamber suggests an air leak from the client or the drainage system. Assess the client first, inspect the system and connections, and promptly notify the responsible team.

Why the other choices do not fit:

A. These are appropriate system conditions, not a new problem.
B. Water-seal movement with respiration can be expected; interpret it with the client and system assessment.
D. This small amount, without an adverse trend or respiratory change, is less concerning than the new continuous air leak. Drainage limits depend on the procedure and orders.

Teaching point. Know which chamber you are assessing. New continuous water-seal bubbling needs assessment; do not routinely clamp the chest tube to address it.

Reduction of Risk Potential · RN26-A-045

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: RCH Nursing Guideline: Chest Drain Management — Drain system observation; bubbling/air leak; positioning

Question 46

An alert adult in the emergency department reports crushing substernal chest pain that began 30 minutes ago. Initial assessment shows a patent airway, normal breathing, and stable circulation. A 12-lead machine is immediately available. Which prescribed diagnostic action should be prioritized?

A. Obtain a 12-lead electrocardiogram
B. Draw blood for cardiac troponin
C. Insert a peripheral intravenous catheter
D. Obtain a portable chest radiograph

Answer and rationale — Question 46

Correct answer:

A prompt 12-lead electrocardiogram can identify ST-segment elevation and guide the urgent cardiac pathway. Obtain it without waiting for troponin or radiography; monitoring, access, and other indicated care can occur alongside it.

Why the other choices do not fit:

B. Troponin results take time and do not rule out an evolving infarction in the first minutes.
C. Intravenous access is useful and can occur concurrently; it does not replace the immediately available diagnostic ECG.
D. A chest radiograph is useful for other causes of chest pain and does not identify an acute infarction.

Teaching point. With suspected acute coronary syndrome, obtain the ECG promptly while continuing assessment and other necessary care.

Physiological Adaptation · RN26-A-046

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: American Heart Association: Acute Coronary Syndrome — Symptoms; How is it diagnosed and treated?

Source: OHSU: Heart Attack Care — Diagnosing a heart attack

Question 47

An adult client admitted with a heart failure exacerbation has been treated for 24 hours. Classify each finding as improved, unchanged, or worsened compared with admission. Measurements were obtained consistently; consider each row separately.

Choose one classification for each row: Improved · Unchanged · Worsened.

Finding or action	Your classification
Weight is 2 kg less than on admission	________
Crackles now heard at the lung bases only, previously to the mid-lung fields	________
Oxygen saturation 96% on room air, previously 90% on 2 L/min	________
Client still requires three pillows to sleep, the same as on admission	________
Urine output 25 mL/hr for the past three hours, previously 70 mL/hr	________

Answer and rationale — Question 47

Correct answer:

Weight is 2 kg less than on admission: Improved
Crackles now heard at the lung bases only, previously to the mid-lung fields: Improved
Oxygen saturation 96% on room air, previously 90% on 2 L/min: Improved
Client still requires three pillows to sleep, the same as on admission: Unchanged
Urine output 25 mL/hr for the past three hours, previously 70 mL/hr: Worsened

Weight, lung sounds, and oxygen requirement all moved in the right direction. Orthopnea has not changed. A drop in urine output to 25 mL/hr is the one finding that has gone the wrong way and needs reporting, since it may reflect falling perfusion or excessive diuresis.

Teaching point. Evaluating outcomes means comparing to the earlier value, not judging whether the number looks normal on its own. Improvement in several findings does not cancel a new low urine-output concern.

Physiological Adaptation · Evaluate outcomes · RN26-A-047

Castleport practice scoring: One point per correctly classified row. Maximum: 5 practice points.

Source: American Heart Association: Warning Signs of Heart Failure — Dyspnea, fluid buildup, weight changes and monitoring

Question 48

A 16-year-old client with a traumatic brain injury is being monitored for increased intracranial pressure. Which set of findings is most concerning?

A. Blood pressure 168/62 mm Hg, heart rate 52/min, irregular respirations
B. Blood pressure 104/70 mm Hg, heart rate 96/min, respirations 18/min
C. Blood pressure 130/84 mm Hg, heart rate 88/min, respirations 20/min
D. Blood pressure 118/76 mm Hg, heart rate 72/min, respirations 16/min

Answer and rationale — Question 48

Correct answer:

Hypertension with a wide pulse pressure, bradycardia, and irregular breathing is a late warning pattern of dangerously increased intracranial pressure. Activate urgent clinical help and support airway and breathing as required.

Why the other choices do not fit:

B. These findings are unremarkable for a client under observation.
C. These findings are within normal limits.
D. These findings are within normal limits.

Teaching point. Recognize the combination, not an isolated number: hypertension, bradycardia, and irregular breathing after head injury require an emergency response.

Physiological Adaptation · RN26-A-048

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: RCH Clinical Practice Guideline: Head Injury — Signs of raised intracranial pressure and deterioration

Question 49

A client with COPD has these arterial blood gas results: pH 7.29, PaCO2 58 mm Hg, HCO3 27 mEq/L. Reference intervals are pH 7.35-7.45, PaCO2 35-45 mm Hg, and HCO3 22-26 mEq/L. Complete the interpretation.

These results indicate ______ — choose from: respiratory acidosis; metabolic acidosis; respiratory alkalosis
and the pH shows ______ — choose from: persistent acidemia; a normal pH; alkalemia

Answer and rationale — Question 49

Correct answer:

respiratory acidosis; persistent acidemia

The pH is below 7.35, indicating acidemia, and the elevated PaCO2 identifies a respiratory acidifying process. The mildly elevated bicarbonate does not normalize the pH. A single sample without the clinical time course and expected compensatory response is not enough to label the disorder acute, chronic, or simply fully/partially compensated.

Teaching point. Identify the pH direction and the primary process first. Assess expected compensation and the clinical time course before assigning an acute/chronic or mixed-disorder label.

Physiological Adaptation · RN26-A-049

Castleport practice scoring: One point only when all linked blanks are correct. Maximum: 1 practice point.

Source: MedlinePlus: Respiratory Acidosis — Causes and compensation

Question 50

A client with chronic kidney disease has a serum potassium of 6.8 mEq/L. Which electrocardiogram change is classically associated with this electrolyte abnormality?

A. Tall, peaked T waves
B. Prominent U waves
C. Shortened QT interval with a normal T wave
D. Inverted P waves with a normal QRS

Answer and rationale — Question 50

Correct answer:

Tall, peaked T waves are a recognized hyperkalemia-associated ECG change. Findings are variable and do not follow a reliable concentration-based sequence; severe hyperkalemia can occur without the classic ECG changes.

Why the other choices do not fit:

B. Prominent U waves are associated with hypokalemia, the opposite problem.
C. A shortened QT interval is associated with hypercalcemia.
D. Inverted P waves are not the characteristic finding in hyperkalemia.

Teaching point. Recognize peaked T waves as a possible clue, but never use a normal ECG to exclude dangerous hyperkalemia.

Physiological Adaptation · RN26-A-050

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: KDIGO Conference Report: Acute Hyperkalemia in the Emergency Department — Medication contributors and ECG changes, printed pp. 331-333

Question 51

An adult client is being treated for diabetic ketoacidosis and is alert when assessed. Select the 3 trends that support improvement. Consider each finding independently.

A. Blood glucose has fallen from 480 mg/dL to 210 mg/dL
B. Serum bicarbonate has risen from 10 mEq/L to 20 mEq/L
C. Respirations are now 18/min and unlabored, previously deep and rapid; the client remains alert
D. Serum potassium has fallen from 4.6 mEq/L to 3.1 mEq/L
E. The client becomes difficult to rouse on repeat assessment

Answer and rationale — Question 51

Correct answer:

A, B, C

Falling glucose, rising bicarbonate, and less labored breathing support a response to treatment, but they do not alone establish resolution of DKA; ketone clearance and acid-base criteria still require assessment.

Why the other choices do not fit:

D. A potassium of 3.1 mEq/L is an urgent treatment-related safety concern, not improvement. Notify the team and follow the DKA protocol for potassium replacement and insulin management.
E. New impaired arousal is deterioration, not improvement, and needs urgent reassessment.

Teaching point. DKA can involve a major total-body potassium deficit even when the initial blood level is normal or high. Insulin and correction of acidosis can lower the measured level further, so replacement and repeated monitoring matter.

Physiological Adaptation · RN26-A-051

Castleport practice scoring: Select exactly the stated number; one point per correct selection. Maximum: 3 practice points.

Source: ADA/EASD and partner societies: Hyperglycaemic Crises in Adults With Diabetes—Consensus Report — Treatment > Potassium; Criteria for resolution

Question 52

A client has a new ileostomy. Which findings require follow-up? Select all that apply.

A. The stoma is dusky purple
B. Output has been 1,800 mL over the past 8 hours
C. The stoma is beefy red and moist
D. The skin around the stoma is excoriated and weeping
E. Output is liquid to paste-like in consistency

Answer and rationale — Question 52

Correct answer:

A, B, D

A dusky stoma suggests compromised blood supply and needs urgent assessment. Very high output risks dehydration and electrolyte loss. Excoriated, weeping skin requires assessment of the fit, leakage, skin exposure, and other possible causes.

Why the other choices do not fit:

C. A beefy red, moist stoma is the expected, healthy appearance.
E. Liquid to paste-like output is expected from an ileostomy.

Teaching point. A healthy stoma is moist and red or pink. Evaluate color, output volume, hydration, and surrounding skin together; an expected stool consistency does not make excessive volume safe.

Physiological Adaptation · RN26-A-052

Castleport practice scoring: Add one per correct selection; subtract one per incorrect selection; minimum zero. Maximum: 3 practice points.

Source: Memorial Sloan Kettering: Caring for Your Ileostomy or Colostomy — Stoma appearance; dehydration/high output; When to call your healthcare provider

Case study 1 — suspected sepsis after abdominal surgery (Questions 53-58)

This six-item case study uses one unfolding client scenario. New information appears as you move through the case.

The client and 0800 assessment

A 68-year-old is one day after an open colectomy for a perforated bowel with intra-abdominal infection. At 0800: temperature 38.8 C (101.8 F), heart rate 118/min, respirations 26/min, blood pressure 94/56 mm Hg, and oxygen saturation 96% on room air. The client is oriented to person and place only, compared with person, place, time, and situation yesterday. Urine output has been 20 mL/hr for two hours. The abdominal incision is clean, dry, and intact with staples in place; sequential compression devices are on both lower legs. Urgent clinical help is requested.

Question 53

Highlight each finding in the 0800 note that requires immediate follow-up.

Select every finding that answers the question.

H1. Temperature 38.8 C (101.8 F).
H2. Heart rate 118/min.
H3. Respirations 26/min.
H4. Blood pressure 94/56 mm Hg.
H5. Oriented to person and place only; was oriented to person, place, time, and situation yesterday.
H6. Urine output 20 mL/hr for the past two hours.
H7. Oxygen saturation 96% on room air.
H8. Abdominal incision clean, dry, and intact with staples in place.
H9. Sequential compression devices in place on both lower legs.

Answer and rationale — Question 53

Correct answer:

Temperature 38.8 C (101.8 F).
Heart rate 118/min.
Respirations 26/min.
Blood pressure 94/56 mm Hg.
Oriented to person and place only; was oriented to person, place, time, and situation yesterday.
Urine output 20 mL/hr for the past two hours.

Six findings are concerning in this context: fever, tachycardia, tachypnea, hypotension, new disorientation, and low urine output. Together with the known intra-abdominal infection they raise concern for sepsis and organ dysfunction, not routine recovery.

Teaching point. Recognize abnormal findings in context and the changes actually documented. The normal oxygen saturation and clean external incision do not rule out an intra-abdominal source.

Reduction of Risk Potential · Recognize cues · RN26-CS1-01

Castleport practice scoring: Add one per correct selection; subtract one per incorrect selection; minimum zero. Maximum: 6 practice points.

0815 and 0830 updates

At 0815, repeat blood pressure is 80/42 mm Hg (estimated MAP 55 mm Hg), and the emergency response team is at the bedside. At 0830, results show white blood cells 18,200/mm3, serum lactate 3.4 mmol/L, and creatinine 1.6 mg/dL compared with a baseline of 0.9 mg/dL. Incisional pain is 5 on a 0-to-10 scale. The client had transferred to a chair earlier, before the deterioration.

Question 54

Classify each finding according to whether it adds support to the current concern for sepsis in this client. No single row establishes or excludes the diagnosis.

Choose one classification for each row: Adds support to the sepsis concern · Does not add support by itself.

Finding or action	Your classification
Temperature 38.8 C with heart rate 118/min and blood pressure 94/56 mm Hg	________
Serum lactate 3.4 mmol/L	________
New disorientation to time and situation	________
Creatinine 1.6 mg/dL, baseline 0.9 mg/dL	________
Incisional pain rated 5 on a 0-to-10 scale on the first day after surgery	________
Ambulated to the chair with assistance earlier, before the acute deterioration	________

Answer and rationale — Question 54

Correct answer:

Temperature 38.8 C with heart rate 118/min and blood pressure 94/56 mm Hg: Adds support to the sepsis concern
Serum lactate 3.4 mmol/L: Adds support to the sepsis concern
New disorientation to time and situation: Adds support to the sepsis concern
Creatinine 1.6 mg/dL, baseline 0.9 mg/dL: Adds support to the sepsis concern
Incisional pain rated 5 on a 0-to-10 scale on the first day after surgery: Does not add support by itself
Ambulated to the chair with assistance earlier, before the acute deterioration: Does not add support by itself

Elevated lactate, a creatinine increase, altered mentation, and the abnormal vital-sign cluster add support to concern for organ dysfunction in a client with infection. Incisional pain and having transferred to a chair earlier do not by themselves add the same support; neither excludes later deterioration.

Teaching point. Use the whole pattern. A finding may add to a hypothesis without being specific enough to diagnose it alone.

Reduction of Risk Potential · Analyze cues · RN26-CS1-02

Castleport practice scoring: One point per correctly classified row. Maximum: 6 practice points.

Question 55

Which explanation for this client's condition should the nurse prioritize?

A. Suspected sepsis associated with an intra-abdominal infection
B. An expected pain response to abdominal surgery
C. Postoperative atelectasis
D. Opioid-induced sedation

Answer and rationale — Question 55

Correct answer:

The known intra-abdominal infection plus fever, abnormal perfusion, altered mentation, oliguria, raised lactate, and rising creatinine make sepsis the priority hypothesis. The team still evaluates the source and competing explanations.

Why the other choices do not fit:

B. Pain does not adequately account for the multisystem deterioration and documented infection.
C. Atelectasis may affect respiratory findings but does not adequately explain this entire perfusion and organ-dysfunction pattern. Do not assume it is the cause of postoperative fever.
D. Opioid toxicity would not adequately explain the documented infection, tachypnea, hypotension, and organ-dysfunction pattern. Medication effects and other causes are still assessed.

Teaching point. Prioritizing hypotheses means choosing the one explanation that accounts for the most cues, especially the dangerous ones.

Physiological Adaptation · Prioritize hypotheses · RN26-CS1-03

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Treatment planning

The provider and emergency response team are evaluating suspected sepsis with hypoperfusion and arranging source assessment. For Question 58, compare each possible follow-up finding independently with its stated pretreatment value; the rows are not a single completed progress note.

Question 56

The provider has been notified. Select the 3 interventions the nurse should anticipate.

A. Obtain blood cultures
B. Administer broad-spectrum intravenous antimicrobials without delay
C. Begin intravenous crystalloid fluid resuscitation
D. Withhold all intravenous fluids until culture results return
E. Give an antipyretic and reassess the client in four hours

Answer and rationale — Question 56

Correct answer:

A, B, C

Current guidance directs clinicians to collect blood cultures as soon as possible and ideally before antimicrobials, to give antimicrobials immediately for suspected septic shock, and to resuscitate with intravenous crystalloid. Cultures are obtained first when that does not delay treatment.

Why the other choices do not fit:

D. Withholding fluids in a hypotensive, hypoperfused client worsens organ injury.
E. An antipyretic alone does not treat the suspected source or poor perfusion; a four-hour delay is unsafe.

Teaching point. Cultures before antimicrobials when you can. Antimicrobials without waiting when you cannot. Those two sentences are not in conflict.

Pharmacological and Parenteral Therapies · Generate solutions · RN26-CS1-04

Castleport practice scoring: Select exactly the stated number; one point per correct selection. Maximum: 3 practice points.

Question 57

Complete the diagram by selecting the priority suspected condition, the two actions the nurse should take, and the two listed parameters the nurse should monitor.

Condition - select 1

Sepsis
Hypoglycemia
Acute pulmonary embolism

Actions to take - select 2

Obtain blood cultures and begin the prescribed intravenous antimicrobials without delay
Begin the prescribed intravenous crystalloid infusion
Encourage the client to drink oral fluids
Place the client in the Trendelenburg position

Parameters to monitor - select 2

Mean arterial pressure
Serum lactate
Bowel sounds
Pupil size

Answer and rationale — Question 57

Correct answer:

Condition - select 1: Sepsis
Actions to take - select 2: Obtain blood cultures and begin the prescribed intravenous antimicrobials without delay; Begin the prescribed intravenous crystalloid infusion
Parameters to monitor - select 2: Mean arterial pressure; Serum lactate

The selected condition fits the documented infection and deterioration. Prescribed antimicrobials and crystalloid resuscitation address urgent treatment needs while the team investigates source control. MAP and serial lactate are useful selected response measures; urine output, mental status, respiratory status, and fluid tolerance also matter. Neither a low glucose nor a pulmonary embolism is established by this case. Oral fluids are not an adequate substitute for prescribed resuscitation in this unstable client, and Trendelenburg positioning does not replace treatment. Bowel sounds and pupil size do not directly track the selected perfusion targets.

Teaching point. In this practice bow-tie, the condition must be correct with each complete linked selection group. The selected monitoring answers are not an exhaustive monitoring plan.

Physiological Adaptation · Take action · RN26-CS1-05

Castleport practice scoring: One point for the correct condition plus the complete correct action group; one for the correct condition plus the complete correct monitoring group. Maximum: 2 practice points.

Question 58

Three hours after treatment began, classify each possible follow-up finding independently as improved, unchanged, or worsened against the stated pretreatment value.

Choose one classification for each row: Improved · Unchanged · Worsened.

Finding or action	Your classification
Mean arterial pressure 68 mm Hg, previously 55 mm Hg	________
Serum lactate 2.1 mmol/L, previously 3.4 mmol/L	________
Urine output 45 mL/hr, previously 20 mL/hr	________
Heart rate remains 118/min	________
Respirations 30/min, previously 26/min	________

Answer and rationale — Question 58

Correct answer:

Mean arterial pressure 68 mm Hg, previously 55 mm Hg: Improved
Serum lactate 2.1 mmol/L, previously 3.4 mmol/L: Improved
Urine output 45 mL/hr, previously 20 mL/hr: Improved
Heart rate remains 118/min: Unchanged
Respirations 30/min, previously 26/min: Worsened

Pressure, lactate, and urine output move in a favorable direction in those rows. Heart rate remains 118/min. The higher respiratory rate is a concerning trend that needs prompt reassessment even when other measures improve.

Teaching point. A partly improving client is still a deteriorating client in one dimension. Report the row that got worse even when most of the others got better.

Physiological Adaptation · Evaluate outcomes · RN26-CS1-06

Castleport practice scoring: One point per correctly classified row. Maximum: 5 practice points.

Case study 2 — a 4-year-old with an asthma exacerbation (Questions 59-64)

This six-item case study uses one unfolding client scenario. New information appears as you move through the case.

The client and triage note

A 4-year-old with a history of asthma arrives in the emergency department with a caregiver after two days of upper respiratory symptoms. Weight is 16 kg. Respirations are 40/min, heart rate 140/min, oxygen saturation 90% on room air, and temperature 36.9 C (98.4 F). There are visible suprasternal and intercostal retractions, diffuse expiratory wheezing audible without a stethoscope, and speech limited to three-word phrases. The child is awake and immunizations are up to date.

Question 59

Highlight each finding in the triage note that indicates the child is in respiratory distress.

Select every finding that answers the question.

H1. Respirations 40/min.
H2. Oxygen saturation 90% on room air.
H3. Visible suprasternal and intercostal retractions.
H4. Speaking in three-word phrases.
H5. Audible expiratory wheeze without a stethoscope.
H6. Temperature 36.9 C (98.4 F).
H7. Weight 16 kg.
H8. Immunizations up to date.

Answer and rationale — Question 59

Correct answer:

Respirations 40/min.
Oxygen saturation 90% on room air.
Visible suprasternal and intercostal retractions.
Speaking in three-word phrases.
Audible expiratory wheeze without a stethoscope.

Tachypnea, low oxygen saturation, retractions, short phrases, and audible wheeze together indicate respiratory distress. Temperature, weight, and immunization status do not themselves demonstrate respiratory compromise in this note.

Teaching point. Speech, work of breathing, air entry, oxygenation, and alertness all inform severity. The number of words is a useful clue, not a stand-alone severity score.

Physiological Adaptation · Recognize cues · RN26-CS2-01

Castleport practice scoring: Add one per correct selection; subtract one per incorrect selection; minimum zero. Maximum: 5 practice points.

Source: RCH Clinical Practice Guideline: Acute Asthma — Key points; Examination; Investigations; Other management considerations

Source: Canadian Paediatric Society: Managing an Acute Asthma Exacerbation in Children — Assessment; Managing the acute asthma exacerbation—oxygen and medications

Question 60

Complete each sentence by choosing the correct option.

The child's retractions and three-word phrases indicate ______ — choose from: increased work of breathing; adequate ventilation; anxiety alone
An oxygen saturation of 90% on room air indicates ______ — choose from: hypoxemia requiring supplemental oxygen; an expected finding in a 4-year-old; a probable sensor error

Answer and rationale — Question 60

Correct answer:

increased work of breathing; hypoxemia requiring supplemental oxygen

Retractions mean the child is recruiting muscles that are not normally needed to breathe, and short phrases mean air is running out before the sentence does. A saturation of 90% on room air in a child is hypoxemia and needs treatment, not a repeat measurement alone. The nurse can verify the signal while treating the clinically distressed child. Adequate ventilation or anxiety alone does not explain the full pattern, and 90% is not an expected healthy saturation for this child.

Teaching point. Do not explain away a low saturation in a child who is visibly working to breathe. Treat it.

Physiological Adaptation · Analyze cues · RN26-CS2-02

Castleport practice scoring: One point only when all linked blanks are correct. Maximum: 1 practice point.

Source: RCH Clinical Practice Guideline: Acute Asthma — Key points; Examination; Investigations; Other management considerations

Source: Canadian Paediatric Society: Managing an Acute Asthma Exacerbation in Children — Assessment; Managing the acute asthma exacerbation—oxygen and medications

Question 61

Which explanation for the child's presentation should the nurse prioritize?

A. Acute asthma exacerbation
B. Croup
C. Foreign body aspiration
D. Bacterial pneumonia

Answer and rationale — Question 61

Correct answer:

A known history of asthma, a preceding upper respiratory infection, diffuse expiratory wheeze, and no fever fit an acute asthma exacerbation triggered by a viral illness.

Why the other choices do not fit:

B. Croup produces inspiratory stridor and a barking cough, not diffuse expiratory wheeze.
C. A sudden choking onset or asymmetric air entry would raise this concern. The documented asthma history and diffuse wheeze following a respiratory illness favor exacerbation, but do not make aspiration impossible.
D. Fever and focal findings would add support for pneumonia. Their absence does not exclude it, but the current pattern favors asthma.

Teaching point. Diffuse expiratory wheeze supports lower-airway obstruction; inspiratory stridor suggests upper-airway obstruction. Neither the sound nor the absence of fever is a complete diagnosis.

Physiological Adaptation · Prioritize hypotheses · RN26-CS2-03

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: RCH Clinical Practice Guideline: Acute Asthma — Key points; Examination; Investigations; Other management considerations

Source: Canadian Paediatric Society: Managing an Acute Asthma Exacerbation in Children — Assessment; Managing the acute asthma exacerbation—oxygen and medications

Question 62

Select the 3 interventions the nurse should anticipate for this child.

A. Administer supplemental oxygen as prescribed
B. Administer the prescribed inhaled short-acting beta-2 agonist
C. Administer the prescribed systemic corticosteroid early
D. Give a sedative solely to quiet the child before treating the respiratory distress
E. Have the child lie flat for a chest radiograph before any treatment

Answer and rationale — Question 62

Correct answer:

A, B, C

Supplemental oxygen addresses hypoxemia, inhaled short-acting bronchodilator treats obstruction, and an early prescribed systemic corticosteroid treats the inflammatory exacerbation. Keep the child comfortable and upright with caregiver support while treatment proceeds.

Why the other choices do not fit:

D. Routine sedation for anxiety can impair respiratory assessment and breathing. Sedation for a separate critical-care procedure requires an appropriately trained team and airway plan.
E. Do not delay indicated treatment to obtain a routine radiograph or force a distressed child flat.

Teaching point. Treat the hypoxemia and obstruction promptly and give the prescribed anti-inflammatory treatment. Routine sedation for anxiety is not a substitute for respiratory treatment.

Pharmacological and Parenteral Therapies · Generate solutions · RN26-CS2-04

Castleport practice scoring: Select exactly the stated number; one point per correct selection. Maximum: 3 practice points.

Source: RCH Clinical Practice Guideline: Acute Asthma — Key points; Examination; Investigations; Other management considerations

Source: Canadian Paediatric Society: Managing an Acute Asthma Exacerbation in Children — Assessment; Managing the acute asthma exacerbation—oxygen and medications

Immediate care

The emergency clinician assesses an acute asthma exacerbation. Supplemental oxygen, an inhaled short-acting bronchodilator, and an early systemic corticosteroid are prescribed. Keep the child in a comfortable upright position with caregiver support. For Question 63, oxygen equipment is ready while a colleague prepares the bronchodilator. Question 64 presents separate possible follow-up findings, not simultaneous findings in one child.

Question 63

Emergency help has been activated. Oxygen is ready at the bedside while a colleague finishes preparing the prescribed bronchodilator. Other prescribed care is being arranged concurrently. For this nurse's available actions, place the following steps in order.

Write the step labels in the correct order.

S3. Reassess respiratory rate, work of breathing, breath sounds, and oxygen saturation
S1. Position the child upright and apply supplemental oxygen as prescribed
S4. Report the response to the provider and document the assessment
S2. Administer the prescribed inhaled short-acting bronchodilator

Answer and rationale — Question 63

Correct answer:

S1 → S2 → S3 → S4

Position the child upright and apply supplemental oxygen as prescribed
Administer the prescribed inhaled short-acting bronchodilator
Reassess respiratory rate, work of breathing, breath sounds, and oxygen saturation
Report the response to the provider and document the assessment

With oxygen already available and the bronchodilator still being prepared, start the available support, give the bronchodilator when ready, then reassess and communicate the response. In routine team care, oxygen and bronchodilator treatment may begin concurrently; this sequence is not a reason to delay either treatment.

Teaching point. Support, treat, reassess, report. The reassessment is not optional paperwork; it is the information that drives the next decision.

Physiological Adaptation · Take action · RN26-CS2-05

Castleport practice scoring: One point per step in its correct position. Maximum: 4 practice points.

Source: RCH Clinical Practice Guideline: Acute Asthma — Key points; Examination; Investigations; Other management considerations

Source: Canadian Paediatric Society: Managing an Acute Asthma Exacerbation in Children — Assessment; Managing the acute asthma exacerbation—oxygen and medications

Question 64

Twenty minutes after treatment, classify each possible finding independently as respiratory improvement, a possible medication effect needing reassessment, or respiratory deterioration.

Choose one classification for each row: Respiratory improvement · Possible medication effect: reassess · Respiratory deterioration.

Finding or action	Your classification
Respirations 28/min, previously 40/min	________
Oxygen saturation 95% on 2 L/min by nasal cannula, previously 90% on room air	________
Speaking in full sentences, previously three-word phrases	________
Heart rate 148/min, previously 140/min, with a fine hand tremor	________
Child is now drowsy and difficult to keep awake	________

Answer and rationale — Question 64

Correct answer:

Respirations 28/min, previously 40/min: Respiratory improvement
Oxygen saturation 95% on 2 L/min by nasal cannula, previously 90% on room air: Respiratory improvement
Speaking in full sentences, previously three-word phrases: Respiratory improvement
Heart rate 148/min, previously 140/min, with a fine hand tremor: Possible medication effect: reassess
Child is now drowsy and difficult to keep awake: Respiratory deterioration

Lower respiratory rate, better oxygenation, and full sentences support respiratory improvement. New tremor with a higher heart rate can follow a beta-2 agonist, but still needs reassessment rather than being called unchanged or automatically harmless. New difficulty staying awake is a respiratory warning requiring immediate reassessment and escalation.

Teaching point. A quiet, sleepy child in an asthma attack is not a calm child. Sudden settling can mean exhaustion.

Physiological Adaptation · Evaluate outcomes · RN26-CS2-06

Castleport practice scoring: One point per correctly classified row. Maximum: 5 practice points.

Source: RCH Clinical Practice Guideline: Acute Asthma — Key points; Examination; Investigations; Other management considerations

Source: Canadian Paediatric Society: Managing an Acute Asthma Exacerbation in Children — Assessment; Managing the acute asthma exacerbation—oxygen and medications

Case study 3 — alcohol withdrawal after surgery (Questions 65-70)

This six-item case study uses one unfolding client scenario. New information appears as you move through the case.

The client and assessment

A 52-year-old is one day after elective hernia repair. The history documents prolonged heavy daily alcohol use and previous tremor when stopping. The last drink was about 30 hours ago. The client has a coarse hand tremor, a damp gown from sweating, heart rate 112/min, and blood pressure 158/94 mm Hg. The client reports bugs crawling on the wall but is oriented to person, place, and time. The surgical site is clean and dry; incisional pain is 3 on a 0-to-10 scale.

Question 65

Highlight each finding in the note that supports a developing alcohol withdrawal syndrome.

Select every finding that answers the question.

H1. Last alcoholic drink approximately 30 hours ago.
H2. Coarse tremor of both hands.
H3. Diaphoretic, with a damp gown.
H4. Heart rate 112/min.
H5. Blood pressure 158/94 mm Hg.
H6. Reports seeing bugs crawling on the wall; oriented to person, place, and time.
H7. Surgical site clean and dry with no drainage.
H8. Reports incisional pain rated 3 on a 0-to-10 scale.

Answer and rationale — Question 65

Correct answer:

Last alcoholic drink approximately 30 hours ago.
Coarse tremor of both hands.
Diaphoretic, with a damp gown.
Heart rate 112/min.
Blood pressure 158/94 mm Hg.
Reports seeing bugs crawling on the wall; oriented to person, place, and time.

In the context of prolonged heavy daily alcohol use and abrupt cessation, tremor, sweating, tachycardia, hypertension, and visual disturbance support alcohol withdrawal. The last-drink timing is relevant, but does not establish the diagnosis by itself.

Teaching point. Ask about amount, pattern, last use, prior withdrawal, and other substances. Combine that history with the clinical assessment rather than using a fixed time window alone.

Psychosocial Integrity · Recognize cues · RN26-CS3-01

Castleport practice scoring: Add one per correct selection; subtract one per incorrect selection; minimum zero. Maximum: 6 practice points.

Source: ASAM: Clinical Practice Guideline on Alcohol Withdrawal Management — Inpatient recommendations V.1-V.7 and V.13-V.18

Question 66

Classify each finding as consistent or not consistent with alcohol withdrawal.

Choose one classification for each row: Consistent with alcohol withdrawal · Not consistent with alcohol withdrawal.

Finding or action	Your classification
Coarse hand tremor	________
Diaphoresis	________
Hypertension with tachycardia	________
Visual perceptual disturbance with preserved orientation	________
Pinpoint pupils with a respiratory rate of 8/min	________

Answer and rationale — Question 66

Correct answer:

Coarse hand tremor: Consistent with alcohol withdrawal
Diaphoresis: Consistent with alcohol withdrawal
Hypertension with tachycardia: Consistent with alcohol withdrawal
Visual perceptual disturbance with preserved orientation: Consistent with alcohol withdrawal
Pinpoint pupils with a respiratory rate of 8/min: Not consistent with alcohol withdrawal

Tremor, sweating, tachycardia, hypertension, and perceptual disturbance fit alcohol withdrawal in this case. Pinpoint pupils with slow breathing instead raise concern for opioid toxicity or another cause of respiratory depression and require urgent assessment.

Teaching point. Match the observed syndrome to the substance history. A finding that does not fit the working diagnosis still needs its own assessment.

Psychosocial Integrity · Analyze cues · RN26-CS3-02

Castleport practice scoring: One point per correctly classified row. Maximum: 5 practice points.

Source: ASAM: Clinical Practice Guideline on Alcohol Withdrawal Management — Inpatient recommendations V.1-V.7 and V.13-V.18

Source: AHA: Adult and Pediatric Special Circumstances of Resuscitation — 21.11 Opioids: respiratory depression with a definite pulse; naloxone and recurrence monitoring

Question 67

Which explanation should the nurse prioritize?

A. Alcohol withdrawal with a risk of progression to withdrawal seizures and delirium
B. Uncontrolled postoperative pain
C. A primary anxiety disorder
D. Opioid intoxication

Answer and rationale — Question 67

Correct answer:

The documented prolonged heavy daily use, previous withdrawal symptoms, recent cessation, autonomic changes, and visual disturbance make alcohol withdrawal the priority explanation. Seizures and delirium are potential complications, so prompt treatment and monitoring are needed.

Why the other choices do not fit:

B. The client rates pain at 3 out of 10 and pain does not cause visual hallucinations.
C. An anxiety disorder does not explain the tremor, sweating, and hallucinations appearing on a specific timeline after the last drink.
D. Opioid intoxication causes sedation, slow breathing, and small pupils, not agitation and hyperadrenergic vital signs.

Teaching point. Use the pattern, history, and time course together. The time since the last drink is a clue, not an independent diagnostic test.

Psychosocial Integrity · Prioritize hypotheses · RN26-CS3-03

Castleport practice scoring: One point for the correct choice. Maximum: 1 practice point.

Source: ASAM: Clinical Practice Guideline on Alcohol Withdrawal Management — Inpatient recommendations V.1-V.7 and V.13-V.18

Assessment and orders

The clinician evaluates alcohol withdrawal, and the pretreatment CIWA-Ar score is documented as 19. The client is awake and breathing normally. The facility has a validated symptom-triggered withdrawal protocol, and the nurse is preparing the indicated safety, medication, and monitoring measures. Medication dosing will follow the actual protocol and safety findings; no universal dose or score-to-dose schedule is supplied in this exercise.

Question 68

Select the 3 interventions the nurse should anticipate.

A. Initiate seizure precautions
B. Administer the prescribed benzodiazepine according to the symptom-triggered protocol based on the withdrawal assessment score
C. Administer prescribed thiamine without delaying any immediately needed glucose
D. Apply physical restraints to prevent injury before symptoms worsen
E. Place the client in a brightly lit, high-stimulation area to maintain alertness

Answer and rationale — Question 68

Correct answer:

A, B, C

Seizure precautions address a major withdrawal risk. The prescribed symptom-triggered benzodiazepine treats withdrawal, and thiamine helps prevent Wernicke encephalopathy. ASAM permits glucose and thiamine in either order or concurrently: give needed glucose without waiting for thiamine.

Why the other choices do not fit:

D. Restraints are not a preventive measure and are the most restrictive option, used only when less restrictive measures have failed and criteria are met.
E. Use a quiet, reassuring, evenly lit environment. Avoid excessive stimulation without placing the client in darkness that can worsen misinterpretation.

Teaching point. Give prescribed thiamine promptly, but do not delay treatment of hypoglycemia or other indicated glucose administration to give it first.

Safety and Infection Prevention and Control · Generate solutions · RN26-CS3-04

Castleport practice scoring: Select exactly the stated number; one point per correct selection. Maximum: 3 practice points.

Source: ASAM: Clinical Practice Guideline on Alcohol Withdrawal Management — Inpatient recommendations V.1-V.7 and V.13-V.18

Source: CMS: State Operations Manual, Appendix A—Hospitals — Tag A-0154, 42 CFR 482.13(e),

Question 69

Complete the diagram by selecting the client's condition, the two actions the nurse should take, and the two parameters the nurse should monitor.

Condition - select 1

Alcohol withdrawal
Opioid withdrawal
Hypoglycemia

Actions to take - select 2

Administer the prescribed benzodiazepine per the symptom-triggered protocol
Initiate seizure precautions and provide a calm, low-stimulus environment with frequent reorientation
Apply physical restraints before symptoms escalate
Withhold all sedating medication until the client is calm

Parameters to monitor - select 2

Withdrawal assessment score
Heart rate and blood pressure
Urine specific gravity
Pupil size

Answer and rationale — Question 69

Correct answer:

Condition - select 1: Alcohol withdrawal
Actions to take - select 2: Administer the prescribed benzodiazepine per the symptom-triggered protocol; Initiate seizure precautions and provide a calm, low-stimulus environment with frequent reorientation
Parameters to monitor - select 2: Withdrawal assessment score; Heart rate and blood pressure

The symptom-triggered benzodiazepine and safety measures address withdrawal. Repeated symptom scores and autonomic vital signs help assess response; also monitor respiratory status, sedation, orientation, hydration, and the need to escalate care. Opioid withdrawal is not supported by the documented substance history, and hypoglycemia has not been demonstrated. Restraints are not preventive treatment for withdrawal; withholding indicated medication leaves it untreated. Urine specific gravity and pupil size are not the best listed measures of withdrawal response.

Teaching point. Symptom-triggered dosing only works if somebody actually rescores the client. The score is the monitoring parameter, not a one-time admission number. A falling score does not replace checking for oversedation or respiratory depression.

Psychosocial Integrity · Take action · RN26-CS3-05

Source: ASAM: Clinical Practice Guideline on Alcohol Withdrawal Management — Inpatient recommendations V.1-V.7 and V.13-V.18

Source: CMS: State Operations Manual, Appendix A—Hospitals — Tag A-0154, 42 CFR 482.13(e),

Question 70

Six hours later the client is awake and breathing normally. The CIWA-Ar withdrawal score is 8, down from the documented pretreatment score of 19. Heart rate is 92/min, blood pressure is 132/78 mm Hg, and visual disturbances have resolved. Complete the sentence.

These findings indicate that treatment has been ______ — choose from: effective so far; ineffective; inconclusive
and the nurse should ______ — choose from: continue monitoring and give further doses only when the protocol indicates; discontinue further monitoring; withhold the prescribed thiamine

Answer and rationale — Question 70

Correct answer:

effective so far; continue monitoring and give further doses only when the protocol indicates

A falling score, settling vital signs, and resolved visual disturbances with preserved wakefulness and breathing support improvement. Continue repeated assessments; give further medication only when the actual protocol or prescription indicates it, rather than automatically dosing because monitoring continues.

Teaching point. Improvement does not end monitoring. Further doses depend on the protocol, current symptoms, and safety assessment.

Psychosocial Integrity · Evaluate outcomes · RN26-CS3-06

Castleport practice scoring: One point only when all linked blanks are correct. Maximum: 1 practice point.

Source: ASAM: Clinical Practice Guideline on Alcohol Withdrawal Management — Inpatient recommendations V.1-V.7 and V.13-V.18

Score yourself

Count only the questions you got fully right. For select-all, matrix, and bow-tie items, count a partly correct answer as a miss for now — you will review those in a moment anyway.

The 52 stand-alone questions are grouped by Client Needs area below. The 18 case-study questions are counted separately, once each.

Section	Questions	Your score
Management of Care	1–9	___ / 9
Safety and Infection Prevention and Control	10–16	___ / 7
Health Promotion and Maintenance	17–21	___ / 5
Psychosocial Integrity	22–26	___ / 5
Basic Care and Comfort	27–31	___ / 5
Pharmacological and Parenteral Therapies	32–39	___ / 8
Reduction of Risk Potential	40–45	___ / 6
Physiological Adaptation	46–52	___ / 7
Case study 1 — sepsis	53–58	___ / 6
Case study 2 — pediatric asthma	59–64	___ / 6
Case study 3 — alcohol withdrawal	65–70	___ / 6
Total	1–70	___ / 70

The line that matters is not the total. Look for repeated missed concepts within the sections. With only five to nine stand-alone questions per area, one miss can change the apparent ranking substantially; use the breakdown to choose review topics, not to diagnose readiness.

What this score means, and what it doesn’t

This practice set has no passing percentage. The NCLEX uses an ability-based passing standard, not a fixed raw percentage that this practice set can reproduce. No practice percentage converts into that official standard. (NCLEX passing standard)

This test is not adaptive, and that is the biggest difference. The live NCLEX uses computerized adaptive testing to select items and evaluate performance against its passing standard. A strong score here is not a guarantee, and a rough score here is not a verdict. (2026 NCLEX-RN Test Plan, printed pp. 15–17)

What the score is genuinely good for is identifying questions and concepts to revisit. The category names match the RN test plan, but a small category sample is not a precise measurement of your ability.

Read the rationale for every question you guessed on, not only the ones you missed. Getting a question right by elimination and getting it right because you understood the client are not the same thing. Check that you can explain the clinical reason, not just recognize the answer.

Why this test has 70 questions

NCSBN publishes the composition of a minimum-length exam in the 2026 test plan. Of the 85 items, 52 are content-area items, 18 form three six-item clinical-judgment case studies, and 15 are unscored pretest items: 52 + 18 + 15 = 85. The live examination can contain 85–150 items, with five hours including breaks. (2026 NCLEX-RN Test Plan, printed p. 15)

Castleport’s editorial choice is to provide 52 stand-alone items and 18 case-study items, with feedback on all 70. That is a substantial practice session, not a full-length CAT simulation. The live exam’s pretest questions do exist; candidates cannot identify them during testing.

How this test was built to the 2026 test plan

The content mix uses the official ranges. We used the midpoint targets as an editorial starting point for allocating the 52 stand-alone questions, then checked each rounded share against its range. These are Castleport item counts, not a promise about any individual adaptive exam. (2026 RN Test Plan, printed p. 5)

Client Needs area	Midpoint target	Questions here	Share of 52	Official range
Management of Care	18%	9	17.3%	15–21%
Safety and Infection Prevention and Control	13%	7	13.5%	10–16%
Health Promotion and Maintenance	9%	5	9.6%	6–12%
Psychosocial Integrity	9%	5	9.6%	6–12%
Basic Care and Comfort	9%	5	9.6%	6–12%
Pharmacological and Parenteral Therapies	16%	8	15.4%	13–19%
Reduction of Risk Potential	12%	6	11.5%	9–15%
Physiological Adaptation	14%	7	13.5%	11–17%
Total	100%	52	100%	—

The case studies follow the clinical judgment model. Each of the three cases runs one client through the six steps NCSBN names: recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action, evaluate outcomes. One question per step, in that order, with new information appearing as the case unfolds. Five stand-alone questions also carry a clinical-judgment tag. This is a content-design choice, not a validation of the set’s difficulty. (2026 RN Test Plan, Clinical Judgment)

The format mix is our editorial choice, not a claim about the exam. NCSBN states there is no predetermined percentage of item formats. The 52 stand-alone items here include 35 single-answer questions and 17 in other formats; the three cases add another 18 items. (NCLEX FAQs, What the Exam Looks Like)

Every question here is original. Castleport’s practice material is unofficial. It is not recalled, leaked, reconstructed, or lightly rewritten live exam content.

Question formats and how practice partial credit works

For the scorecard, count fully correct questions out of 70. The optional partial-credit method shown with each answer gives more detail about what you understood. It totals 150 available practice points, not 150 questions, and does not produce an NCLEX score.

Response type	Castleport practice rule
Single answer or calculation	One point for the correct answer.
Select all that apply or highlight	Add one point for each correct selection and subtract one for each incorrect selection; the item cannot score below zero.
Select a stated number	Choose exactly the stated number. Each correct selection earns one point.
Matrix	One point for each correctly classified row.
Ordered response	One point for each step in its correct position.
Linked blanks	One point only when every linked blank is correct.
Bow-tie	One point for the correct condition with the complete correct action group; one point for the correct condition with the complete correct monitoring group.

These are transparent Castleport practice rules. The live NCLEX uses NCSBN’s item-scoring methods and CAT decision rules; a visual format alone does not make this implementation an official scoring simulation. An unanswered question is not evidence of a clinical misconception. (2026 RN Test Plan, Item Scoring)

What to do with the questions you missed

Volume is not the point. Work through the reason for a miss before moving on.

Read every rationale before you look at your total. The total tempts you into a verdict. The rationales tell you what to do.
Sort your misses by content area using the scorecard above.
For each miss, write one line: the cue you overlooked or the rule you had backwards. Not "I need to study pharmacology." Something like "I treated a falling urine output as fluid balance instead of perfusion."
Re-answer the missed question a day later without looking at the rationale. Explain why the other choices do not fit, rather than memorizing the letter.
If one area accounts for several misses, study that content before doing another mixed set. More questions in an area you do not understand yet mostly produces more misses.

Where to go next

Use NCSBN’s own free materials. The NCLEX Prepare page links to official sample questions, an exam preview, the candidate tutorial, the candidate bulletin, and the test plans. Use these to see the exam owner’s examples and instructions.

For related RN exam context, visit the NCLEX-RN exam prep hub. Completing this set and reviewing your explanations is also a complete next step; another click is not required.

Questions people ask about free NCLEX-RN practice tests

Are these real NCLEX questions?

No. These are original, unofficial practice items. NCSBN separately publishes authorized sample materials; those should not be confused with recalled or leaked live exam questions.

How many do I need to get right?

This set has no validated passing threshold. Use the explanations and missed concepts to plan review. The real NCLEX does have an official passing standard, but not a fixed practice percentage that can be copied onto this set. (NCLEX passing standard)

Is this practice test adaptive like the real exam?

No. Everyone sees the same 70 questions in the same order. The live NCLEX selects items adaptively; this set does not reproduce that process. (2026 RN Test Plan)

Is it matched to the current test plan?

It uses the 2026 NCLEX-RN Test Plan, effective April 1, 2026 through March 31, 2029, and the content-allocation table shows the arithmetic. That maps the categories and case-study structure, not the official exam’s psychometric properties. (NCLEX Test Plans)

Do I need an account or an email address?

No. Every question, answer, and rationale on this page is free and visible without signing up for anything.

Where do the clinical answers come from?

The test plan tells us which topics belong on the exam. It is not authority for a clinical answer. Specific clinical guidelines, authored nursing references, medication information, and regulatory sources are linked beside the relevant explanation. Where a question supplies an individual order or facility policy, use that stated condition rather than treating it as a universal rule.

Can I use this as a readable study set?

Yes. All 70 questions and their explanations are on this page. Open an answer when you are ready to check it; no separate resource is needed.

Sources and editorial information

Last verified: September 21, 2026. This date covers the official exam facts and the cited clinical-source passages checked for this version.

NCSBN, 2026 NCLEX-RN Test Plan: current category ranges, exam length, case structure, CAT and scoring.
NCLEX, Test Plans, FAQs, Passing Standard, and Prepare.
NCSBN, 2026 Candidate Bulletin: candidate instructions and testing-service information.
Clinical and safety sources are linked with each item’s rationale, so the supporting reference stays beside the teaching point.

Written by the Castleport Test Prep Editorial Team. AI tools assisted with drafting, source checking, and consistency checks. This educational practice resource does not replace clinical supervision, current prescriptions, or local clinical protocols.

Castleport Test Prep is an independent publisher of exam preparation materials. It is not affiliated with, endorsed by, or approved by the National Council of State Boards of Nursing, Pearson, or any nursing regulatory body. Exam, organization, and credential names identify their subjects; trademarks belong to their respective owners. The 70 questions on this page are original, unofficial practice items. They are not official, recalled, or live exam content, and no score on this page predicts an NCLEX result, eligibility, or licensure.

Methodology · Editorial standards