BSN Exit Examination Practice
Questions & [Verified Answers], Plus
Explained Rationales|2026 Latest
Update| Instant Download PDF
1. A nurse is caring for a client who suddenly develops dyspnea,
chest pain, and tachycardia after surgery. Which action should the
nurse take first?
A. Administer prescribed analgesic medication
B. Encourage the client to ambulate
C. Apply oxygen and assess respiratory status
D. Place the client in a supine position
Answer: C. Apply oxygen and assess respiratory status
Rationale: Acute dyspnea and chest pain following surgery may
indicate pulmonary embolism. The priority is to support oxygenation
and rapidly assess respiratory status.
2. A client with heart failure is receiving furosemide. Which finding
requires the nurse's immediate attention?
A. Urine output of 1,500 mL/day
B. Potassium level of 2.8 mEq/L
C. Blood pressure of 118/70 mmHg
D. Weight loss of 1 kg over 2 days
Answer: B. Potassium level of 2.8 mEq/L
1|Page
,Rationale: Furosemide can cause significant potassium loss. Severe
hypokalemia increases the risk for potentially life-threatening
dysrhythmias and requires prompt intervention.
3. A nurse is assessing a client with suspected increased intracranial
pressure. Which finding is most concerning?
A. Headache
B. Vomiting
C. Decreased level of consciousness
D. Mild photophobia
Answer: C. Decreased level of consciousness
Rationale: A decreasing level of consciousness is an important
indicator of deteriorating neurologic function and increased
intracranial pressure. It requires immediate assessment and
intervention.
4. A client with diabetes mellitus is confused, diaphoretic, and
trembling. The client's blood glucose is 48 mg/dL. Which
intervention is appropriate if the client is conscious and able to
swallow?
A. Administer 15 g of rapid-acting carbohydrate
B. Administer scheduled insulin
C. Restrict oral fluids
D. Give a high-protein meal only
Answer: A. Administer 15 g of rapid-acting carbohydrate
2|Page
,Rationale: A conscious client with symptomatic hypoglycemia should
receive approximately 15 g of fast-acting carbohydrate, followed by
reassessment of blood glucose.
5. Which assessment finding is most characteristic of left-sided heart
failure?
A. Jugular venous distention
B. Peripheral edema
C. Pulmonary crackles
D. Enlarged liver
Answer: C. Pulmonary crackles
Rationale: Left-sided heart failure causes pulmonary congestion
because the left ventricle cannot effectively pump blood into systemic
circulation. Crackles, dyspnea, and pulmonary edema may result.
6. A client is receiving a blood transfusion and develops chills, fever,
and low back pain. What should the nurse do first?
A. Slow the transfusion
B. Stop the transfusion immediately
C. Administer acetaminophen
D. Obtain a urine specimen
Answer: B. Stop the transfusion immediately
Rationale: Fever, chills, and back pain may indicate an acute
hemolytic transfusion reaction. The transfusion must be stopped
immediately, and the IV line should be maintained with appropriate
compatible fluid according to institutional protocol.
3|Page
, 7. A nurse is caring for a client with chronic obstructive pulmonary
disease who has an oxygen saturation of 86%. Which action is
most appropriate?
A. Withhold oxygen because of chronic CO₂ retention
B. Administer prescribed oxygen and monitor respiratory status
C. Place the client flat in bed
D. Encourage rapid deep breathing
Answer: B. Administer prescribed oxygen and monitor respiratory
status
Rationale: Hypoxemia must be treated. Oxygen should be
administered as prescribed and titrated to the target saturation
ordered for the client while respiratory status is closely monitored.
8. A client with a potassium level of 6.7 mEq/L has peaked T waves
on the ECG. Which intervention should the nurse anticipate?
A. Potassium supplementation
B. IV calcium administration
C. Increased dietary potassium
D. Administration of a potassium-sparing diuretic
Answer: B. IV calcium administration
Rationale: Severe hyperkalemia with ECG changes is a medical
emergency. IV calcium helps stabilize the cardiac membrane while
other treatments lower the serum potassium level.
4|Page
Questions & [Verified Answers], Plus
Explained Rationales|2026 Latest
Update| Instant Download PDF
1. A nurse is caring for a client who suddenly develops dyspnea,
chest pain, and tachycardia after surgery. Which action should the
nurse take first?
A. Administer prescribed analgesic medication
B. Encourage the client to ambulate
C. Apply oxygen and assess respiratory status
D. Place the client in a supine position
Answer: C. Apply oxygen and assess respiratory status
Rationale: Acute dyspnea and chest pain following surgery may
indicate pulmonary embolism. The priority is to support oxygenation
and rapidly assess respiratory status.
2. A client with heart failure is receiving furosemide. Which finding
requires the nurse's immediate attention?
A. Urine output of 1,500 mL/day
B. Potassium level of 2.8 mEq/L
C. Blood pressure of 118/70 mmHg
D. Weight loss of 1 kg over 2 days
Answer: B. Potassium level of 2.8 mEq/L
1|Page
,Rationale: Furosemide can cause significant potassium loss. Severe
hypokalemia increases the risk for potentially life-threatening
dysrhythmias and requires prompt intervention.
3. A nurse is assessing a client with suspected increased intracranial
pressure. Which finding is most concerning?
A. Headache
B. Vomiting
C. Decreased level of consciousness
D. Mild photophobia
Answer: C. Decreased level of consciousness
Rationale: A decreasing level of consciousness is an important
indicator of deteriorating neurologic function and increased
intracranial pressure. It requires immediate assessment and
intervention.
4. A client with diabetes mellitus is confused, diaphoretic, and
trembling. The client's blood glucose is 48 mg/dL. Which
intervention is appropriate if the client is conscious and able to
swallow?
A. Administer 15 g of rapid-acting carbohydrate
B. Administer scheduled insulin
C. Restrict oral fluids
D. Give a high-protein meal only
Answer: A. Administer 15 g of rapid-acting carbohydrate
2|Page
,Rationale: A conscious client with symptomatic hypoglycemia should
receive approximately 15 g of fast-acting carbohydrate, followed by
reassessment of blood glucose.
5. Which assessment finding is most characteristic of left-sided heart
failure?
A. Jugular venous distention
B. Peripheral edema
C. Pulmonary crackles
D. Enlarged liver
Answer: C. Pulmonary crackles
Rationale: Left-sided heart failure causes pulmonary congestion
because the left ventricle cannot effectively pump blood into systemic
circulation. Crackles, dyspnea, and pulmonary edema may result.
6. A client is receiving a blood transfusion and develops chills, fever,
and low back pain. What should the nurse do first?
A. Slow the transfusion
B. Stop the transfusion immediately
C. Administer acetaminophen
D. Obtain a urine specimen
Answer: B. Stop the transfusion immediately
Rationale: Fever, chills, and back pain may indicate an acute
hemolytic transfusion reaction. The transfusion must be stopped
immediately, and the IV line should be maintained with appropriate
compatible fluid according to institutional protocol.
3|Page
, 7. A nurse is caring for a client with chronic obstructive pulmonary
disease who has an oxygen saturation of 86%. Which action is
most appropriate?
A. Withhold oxygen because of chronic CO₂ retention
B. Administer prescribed oxygen and monitor respiratory status
C. Place the client flat in bed
D. Encourage rapid deep breathing
Answer: B. Administer prescribed oxygen and monitor respiratory
status
Rationale: Hypoxemia must be treated. Oxygen should be
administered as prescribed and titrated to the target saturation
ordered for the client while respiratory status is closely monitored.
8. A client with a potassium level of 6.7 mEq/L has peaked T waves
on the ECG. Which intervention should the nurse anticipate?
A. Potassium supplementation
B. IV calcium administration
C. Increased dietary potassium
D. Administration of a potassium-sparing diuretic
Answer: B. IV calcium administration
Rationale: Severe hyperkalemia with ECG changes is a medical
emergency. IV calcium helps stabilize the cardiac membrane while
other treatments lower the serum potassium level.
4|Page
