BSN Comprehensive Exit Assessment
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, tachycardia, and an oxygen saturation of 86%. Which
action should the nurse take first?
A. Obtain a 12-lead electrocardiogram
B. Apply oxygen and assess respiratory status
C. Administer prescribed morphine
D. Prepare the client for a chest CT
Answer: B. Apply oxygen and assess respiratory status
Rationale: The client is exhibiting signs of acute hypoxemia and
possible pulmonary embolism. The priority is to support oxygenation
and perform an immediate respiratory assessment. Diagnostic testing
and medications follow stabilization of the airway and breathing.
2. A client with heart failure is being discharged. Which statement
indicates that the client understands the importance of daily
weight monitoring?
A. “I will weigh myself once a week.”
B. “I will weigh myself after dinner every day.”
1|Page
,C. “I will weigh myself every morning using the same scale.”
D. “I will weigh myself whenever my ankles become swollen.”
Answer: C. “I will weigh myself every morning using the same scale.”
Rationale: Daily weights provide an early indication of fluid retention.
The client should weigh themselves at approximately the same time
each morning, preferably after voiding and before eating, using the
same scale and similar clothing.
3. A postoperative client has a respiratory rate of 8/min, is difficult
to arouse, and has pinpoint pupils after receiving IV opioid
analgesia. Which medication should the nurse anticipate
administering?
A. Flumazenil
B. Naloxone
C. Atropine
D. Protamine sulfate
Answer: B. Naloxone
Rationale: Naloxone is an opioid antagonist used to reverse opioid-
induced respiratory depression and central nervous system
depression. The nurse should support ventilation while administering
naloxone as prescribed.
4. A nurse is assessing a client with suspected hypovolemic shock.
Which finding is most consistent with this condition?
A. Bradycardia and warm skin
B. Hypertension and bounding pulses
2|Page
,C. Tachycardia and cool, clammy skin
D. Slow respiratory rate and flushed skin
Answer: C. Tachycardia and cool, clammy skin
Rationale: Hypovolemic shock causes reduced circulating volume,
resulting in compensatory tachycardia and peripheral
vasoconstriction. Cool, pale, clammy skin and weak peripheral pulses
are common findings.
5. A client with type 1 diabetes mellitus is experiencing diabetic
ketoacidosis. Which intervention is the priority?
A. Administer IV regular insulin immediately
B. Begin isotonic IV fluid replacement
C. Administer oral potassium
D. Restrict fluid intake
Answer: B. Begin isotonic IV fluid replacement
Rationale: Severe dehydration is a major consequence of diabetic
ketoacidosis. Initial management generally prioritizes restoration of
intravascular volume with isotonic fluids, followed by insulin therapy
and careful electrolyte management.
6. A client receiving a blood transfusion develops chills, fever, and
low back pain 15 minutes after the transfusion begins. What
should the nurse do first?
A. Slow the transfusion
B. Stop the transfusion
C. Administer acetaminophen
D. Obtain a urine specimen
3|Page
, Answer: B. Stop the transfusion
Rationale: Fever, chills, and low back pain may indicate an acute
hemolytic transfusion reaction. The transfusion must be stopped
immediately, and the nurse should maintain IV access with
appropriate compatible fluid according to institutional protocol and
notify the provider and blood bank.
7. A client with chronic obstructive pulmonary disease is receiving
oxygen. Which oxygen-delivery approach is generally most
appropriate for a client who requires precise low-concentration
oxygen?
A. Nonrebreather mask
B. Venturi mask
C. Simple face mask
D. Partial-rebreather mask
Answer: B. Venturi mask
Rationale: A Venturi mask delivers a precise, controlled oxygen
concentration and is useful when accurate oxygen delivery is
important, including for some clients with COPD who are at risk for
carbon dioxide retention.
8. A nurse is caring for a client with increased intracranial pressure.
Which intervention is appropriate?
A. Keep the neck flexed
B. Position the client flat
C. Maintain the head and neck in neutral alignment
D. Encourage frequent coughing
4|Page
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, tachycardia, and an oxygen saturation of 86%. Which
action should the nurse take first?
A. Obtain a 12-lead electrocardiogram
B. Apply oxygen and assess respiratory status
C. Administer prescribed morphine
D. Prepare the client for a chest CT
Answer: B. Apply oxygen and assess respiratory status
Rationale: The client is exhibiting signs of acute hypoxemia and
possible pulmonary embolism. The priority is to support oxygenation
and perform an immediate respiratory assessment. Diagnostic testing
and medications follow stabilization of the airway and breathing.
2. A client with heart failure is being discharged. Which statement
indicates that the client understands the importance of daily
weight monitoring?
A. “I will weigh myself once a week.”
B. “I will weigh myself after dinner every day.”
1|Page
,C. “I will weigh myself every morning using the same scale.”
D. “I will weigh myself whenever my ankles become swollen.”
Answer: C. “I will weigh myself every morning using the same scale.”
Rationale: Daily weights provide an early indication of fluid retention.
The client should weigh themselves at approximately the same time
each morning, preferably after voiding and before eating, using the
same scale and similar clothing.
3. A postoperative client has a respiratory rate of 8/min, is difficult
to arouse, and has pinpoint pupils after receiving IV opioid
analgesia. Which medication should the nurse anticipate
administering?
A. Flumazenil
B. Naloxone
C. Atropine
D. Protamine sulfate
Answer: B. Naloxone
Rationale: Naloxone is an opioid antagonist used to reverse opioid-
induced respiratory depression and central nervous system
depression. The nurse should support ventilation while administering
naloxone as prescribed.
4. A nurse is assessing a client with suspected hypovolemic shock.
Which finding is most consistent with this condition?
A. Bradycardia and warm skin
B. Hypertension and bounding pulses
2|Page
,C. Tachycardia and cool, clammy skin
D. Slow respiratory rate and flushed skin
Answer: C. Tachycardia and cool, clammy skin
Rationale: Hypovolemic shock causes reduced circulating volume,
resulting in compensatory tachycardia and peripheral
vasoconstriction. Cool, pale, clammy skin and weak peripheral pulses
are common findings.
5. A client with type 1 diabetes mellitus is experiencing diabetic
ketoacidosis. Which intervention is the priority?
A. Administer IV regular insulin immediately
B. Begin isotonic IV fluid replacement
C. Administer oral potassium
D. Restrict fluid intake
Answer: B. Begin isotonic IV fluid replacement
Rationale: Severe dehydration is a major consequence of diabetic
ketoacidosis. Initial management generally prioritizes restoration of
intravascular volume with isotonic fluids, followed by insulin therapy
and careful electrolyte management.
6. A client receiving a blood transfusion develops chills, fever, and
low back pain 15 minutes after the transfusion begins. What
should the nurse do first?
A. Slow the transfusion
B. Stop the transfusion
C. Administer acetaminophen
D. Obtain a urine specimen
3|Page
, Answer: B. Stop the transfusion
Rationale: Fever, chills, and low back pain may indicate an acute
hemolytic transfusion reaction. The transfusion must be stopped
immediately, and the nurse should maintain IV access with
appropriate compatible fluid according to institutional protocol and
notify the provider and blood bank.
7. A client with chronic obstructive pulmonary disease is receiving
oxygen. Which oxygen-delivery approach is generally most
appropriate for a client who requires precise low-concentration
oxygen?
A. Nonrebreather mask
B. Venturi mask
C. Simple face mask
D. Partial-rebreather mask
Answer: B. Venturi mask
Rationale: A Venturi mask delivers a precise, controlled oxygen
concentration and is useful when accurate oxygen delivery is
important, including for some clients with COPD who are at risk for
carbon dioxide retention.
8. A nurse is caring for a client with increased intracranial pressure.
Which intervention is appropriate?
A. Keep the neck flexed
B. Position the client flat
C. Maintain the head and neck in neutral alignment
D. Encourage frequent coughing
4|Page
