BSN3A Nursing Objective Assessment
Practice Questions & [Verified Answers],
Plus Explained Rationales|2026 Latest
Update| Instant Download PDF
1. A nurse is assessing a patient who has developed sudden shortness
of breath and chest pain. Which assessment finding requires the most
immediate intervention?
A. Respiratory rate of 22/min
B. Oxygen saturation of 96%
C. Sudden dyspnea with cyanosis
D. Mild anxiety
Answer: C. Sudden dyspnea with cyanosis
Rationale: Sudden dyspnea accompanied by cyanosis indicates
significant impairment of oxygenation and may represent a life-
threatening respiratory or cardiovascular emergency. The nurse
should prioritize airway and breathing and initiate immediate
assessment and intervention.
2. Which nursing action is most appropriate when administering
medication through an enteral feeding tube?
A. Mix all medications together
B. Crush every medication before administration
C. Verify whether each medication can be crushed
D. Add medications directly to the feeding formula
1|Page
,Answer: C. Verify whether each medication can be crushed
Rationale: Some medications, such as extended-release and enteric-
coated preparations, should not be crushed because doing so can alter
drug absorption or cause toxicity. Medications should generally be
administered separately with appropriate tube flushing.
3. A patient with heart failure is being monitored for fluid overload.
Which finding is most concerning?
A. Weight loss of 0.5 kg in one week
B. Bilateral crackles and increasing dyspnea
C. Blood pressure of 118/72 mmHg
D. Urine output of 1,500 mL/day
Answer: B. Bilateral crackles and increasing dyspnea
Rationale: Crackles and worsening dyspnea suggest pulmonary
congestion caused by fluid overload. This can progress to pulmonary
edema and requires prompt nursing assessment and intervention.
4. Which laboratory value should the nurse recognize as most
important when monitoring a patient receiving warfarin?
A. Serum sodium
B. INR
C. Serum calcium
D. Hemoglobin A1c
Answer: B. INR
Rationale: The international normalized ratio (INR) is used to monitor
the therapeutic effect of warfarin. Excessively elevated values
2|Page
,increase the risk of bleeding, while insufficient anticoagulation
increases the risk of thrombosis.
5. A patient with diabetes mellitus becomes sweaty, shaky, and
confused. What should the nurse suspect?
A. Hypercalcemia
B. Hypoglycemia
C. Hypernatremia
D. Hyperglycemia
Answer: B. Hypoglycemia
Rationale: Sweating, tremors, confusion, weakness, and behavioral
changes are common manifestations of hypoglycemia. Blood glucose
should be checked promptly, and appropriate treatment should be
provided based on the patient's condition.
6. Which assessment finding is 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 blood to back up into the
pulmonary circulation, producing pulmonary congestion and crackles.
Right-sided heart failure more commonly produces systemic venous
congestion such as peripheral edema and jugular venous distention.
3|Page
, 7. A patient is receiving an opioid analgesic. Which finding requires
immediate nursing intervention?
A. Pain rating of 3/10
B. Respiratory rate of 8/min
C. Mild nausea
D. Drowsiness after administration
Answer: B. Respiratory rate of 8/min
Rationale: Opioids can cause respiratory depression. A respiratory
rate of 8/min is dangerously low and requires immediate assessment
and intervention, including consideration of opioid reversal according
to clinical protocols.
8. Which intervention is most effective for preventing pressure
injuries in an immobile patient?
A. Massage reddened areas
B. Reposition the patient regularly
C. Restrict fluid intake
D. Keep the head of the bed elevated continuously
Answer: B. Reposition the patient regularly
Rationale: Regular repositioning relieves prolonged pressure over
bony prominences and is a major component of pressure-injury
prevention. Reddened areas should not be vigorously massaged
because tissue damage may worsen.
4|Page
Practice Questions & [Verified Answers],
Plus Explained Rationales|2026 Latest
Update| Instant Download PDF
1. A nurse is assessing a patient who has developed sudden shortness
of breath and chest pain. Which assessment finding requires the most
immediate intervention?
A. Respiratory rate of 22/min
B. Oxygen saturation of 96%
C. Sudden dyspnea with cyanosis
D. Mild anxiety
Answer: C. Sudden dyspnea with cyanosis
Rationale: Sudden dyspnea accompanied by cyanosis indicates
significant impairment of oxygenation and may represent a life-
threatening respiratory or cardiovascular emergency. The nurse
should prioritize airway and breathing and initiate immediate
assessment and intervention.
2. Which nursing action is most appropriate when administering
medication through an enteral feeding tube?
A. Mix all medications together
B. Crush every medication before administration
C. Verify whether each medication can be crushed
D. Add medications directly to the feeding formula
1|Page
,Answer: C. Verify whether each medication can be crushed
Rationale: Some medications, such as extended-release and enteric-
coated preparations, should not be crushed because doing so can alter
drug absorption or cause toxicity. Medications should generally be
administered separately with appropriate tube flushing.
3. A patient with heart failure is being monitored for fluid overload.
Which finding is most concerning?
A. Weight loss of 0.5 kg in one week
B. Bilateral crackles and increasing dyspnea
C. Blood pressure of 118/72 mmHg
D. Urine output of 1,500 mL/day
Answer: B. Bilateral crackles and increasing dyspnea
Rationale: Crackles and worsening dyspnea suggest pulmonary
congestion caused by fluid overload. This can progress to pulmonary
edema and requires prompt nursing assessment and intervention.
4. Which laboratory value should the nurse recognize as most
important when monitoring a patient receiving warfarin?
A. Serum sodium
B. INR
C. Serum calcium
D. Hemoglobin A1c
Answer: B. INR
Rationale: The international normalized ratio (INR) is used to monitor
the therapeutic effect of warfarin. Excessively elevated values
2|Page
,increase the risk of bleeding, while insufficient anticoagulation
increases the risk of thrombosis.
5. A patient with diabetes mellitus becomes sweaty, shaky, and
confused. What should the nurse suspect?
A. Hypercalcemia
B. Hypoglycemia
C. Hypernatremia
D. Hyperglycemia
Answer: B. Hypoglycemia
Rationale: Sweating, tremors, confusion, weakness, and behavioral
changes are common manifestations of hypoglycemia. Blood glucose
should be checked promptly, and appropriate treatment should be
provided based on the patient's condition.
6. Which assessment finding is 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 blood to back up into the
pulmonary circulation, producing pulmonary congestion and crackles.
Right-sided heart failure more commonly produces systemic venous
congestion such as peripheral edema and jugular venous distention.
3|Page
, 7. A patient is receiving an opioid analgesic. Which finding requires
immediate nursing intervention?
A. Pain rating of 3/10
B. Respiratory rate of 8/min
C. Mild nausea
D. Drowsiness after administration
Answer: B. Respiratory rate of 8/min
Rationale: Opioids can cause respiratory depression. A respiratory
rate of 8/min is dangerously low and requires immediate assessment
and intervention, including consideration of opioid reversal according
to clinical protocols.
8. Which intervention is most effective for preventing pressure
injuries in an immobile patient?
A. Massage reddened areas
B. Reposition the patient regularly
C. Restrict fluid intake
D. Keep the head of the bed elevated continuously
Answer: B. Reposition the patient regularly
Rationale: Regular repositioning relieves prolonged pressure over
bony prominences and is a major component of pressure-injury
prevention. Reddened areas should not be vigorously massaged
because tissue damage may worsen.
4|Page
