BSN3A Nursing Clinical Judgment Exam
Practice Questions & [Verified Answers],
Plus Explained Rationales|2026 Latest
Update| Instant Download PDF
Question 1
A nurse assesses a postoperative client who suddenly becomes restless
and reports difficulty breathing. The oxygen saturation is 88% on room
air. Which action should the nurse take first?
A. Administer the prescribed analgesic
B. Apply supplemental oxygen and assess respiratory status
C. Obtain a complete pain history
D. Encourage the client to ambulate
Rationale: The nurse should prioritize airway and breathing.
Supplemental oxygen and immediate respiratory assessment address
the client's acute hypoxemia while further interventions are
determined.
Question 2
A client with heart failure has gained 2 kg (4.4 lb) in 3 days and has
bilateral crackles. Which finding is most concerning?
A. Mild fatigue
B. Ankle edema
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,C. Increasing respiratory difficulty
D. Decreased appetite
Rationale: Increasing respiratory difficulty with crackles suggests
worsening pulmonary congestion and possible acute pulmonary
edema, requiring prompt intervention.
Question 3
A nurse is caring for a client receiving IV antibiotics. Ten minutes after
administration begins, the client develops wheezing, facial swelling, and
hypotension. What is the priority action?
A. Slow the infusion
B. Document the findings
C. Stop the infusion and initiate emergency measures
D. Reassess the client in 30 minutes
Rationale: These findings indicate a potentially life-threatening
hypersensitivity reaction. The medication should be stopped
immediately and emergency treatment initiated according to
protocol.
Question 4
A client with diabetes is confused, diaphoretic, and trembling. The
blood glucose level is 48 mg/dL. What should the nurse do first if the
client is awake and able to swallow?
A. Administer long-acting insulin
B. Give a rapid-acting source of glucose
C. Encourage exercise
D. Restrict oral fluids
2|Page
,Rationale: The manifestations are consistent with hypoglycemia. An
alert client who can swallow should receive rapidly absorbed
carbohydrate, followed by reassessment.
Question 5
A client with pneumonia has a respiratory rate of 30/min, oxygen
saturation of 89%, and increasing confusion. Which finding requires the
most immediate intervention?
A. Productive cough
B. Temperature of 38.1°C (100.6°F)
C. Oxygen saturation of 89% with confusion
D. Decreased appetite
Rationale: Hypoxemia accompanied by altered mental status indicates
impaired oxygenation and possible deterioration. Airway and
breathing take priority.
Question 6
A client reports crushing chest pain radiating to the left arm and is
diaphoretic. What should the nurse do first?
A. Provide a meal
B. Assess vital signs and initiate emergency cardiac assessment
C. Encourage ambulation
D. Place the client in a flat position
Rationale: The symptoms suggest acute coronary syndrome.
Immediate assessment, cardiac monitoring, and emergency
interventions are necessary.
3|Page
, Question 7
A client taking warfarin reports black, tarry stools. Which nursing action
is most appropriate?
A. Reassure the client that this is expected
B. Encourage increased vitamin K intake immediately
C. Assess for gastrointestinal bleeding and notify the provider
D. Administer the next dose early
Rationale: Black, tarry stools can indicate gastrointestinal bleeding.
Anticoagulated clients require prompt assessment and provider
notification.
Question 8
A client with chronic kidney disease has potassium of 6.3 mEq/L. Which
assessment finding is most concerning?
A. Dry skin
B. Fatigue
C. Cardiac dysrhythmia
D. Mild nausea
Rationale: Severe hyperkalemia can cause life-threatening cardiac
conduction abnormalities and dysrhythmias. Cardiac assessment and
monitoring are priorities.
Question 9
A client with a head injury becomes increasingly difficult to arouse and
develops unequal pupils. What should the nurse recognize?
4|Page
Practice Questions & [Verified Answers],
Plus Explained Rationales|2026 Latest
Update| Instant Download PDF
Question 1
A nurse assesses a postoperative client who suddenly becomes restless
and reports difficulty breathing. The oxygen saturation is 88% on room
air. Which action should the nurse take first?
A. Administer the prescribed analgesic
B. Apply supplemental oxygen and assess respiratory status
C. Obtain a complete pain history
D. Encourage the client to ambulate
Rationale: The nurse should prioritize airway and breathing.
Supplemental oxygen and immediate respiratory assessment address
the client's acute hypoxemia while further interventions are
determined.
Question 2
A client with heart failure has gained 2 kg (4.4 lb) in 3 days and has
bilateral crackles. Which finding is most concerning?
A. Mild fatigue
B. Ankle edema
1|Page
,C. Increasing respiratory difficulty
D. Decreased appetite
Rationale: Increasing respiratory difficulty with crackles suggests
worsening pulmonary congestion and possible acute pulmonary
edema, requiring prompt intervention.
Question 3
A nurse is caring for a client receiving IV antibiotics. Ten minutes after
administration begins, the client develops wheezing, facial swelling, and
hypotension. What is the priority action?
A. Slow the infusion
B. Document the findings
C. Stop the infusion and initiate emergency measures
D. Reassess the client in 30 minutes
Rationale: These findings indicate a potentially life-threatening
hypersensitivity reaction. The medication should be stopped
immediately and emergency treatment initiated according to
protocol.
Question 4
A client with diabetes is confused, diaphoretic, and trembling. The
blood glucose level is 48 mg/dL. What should the nurse do first if the
client is awake and able to swallow?
A. Administer long-acting insulin
B. Give a rapid-acting source of glucose
C. Encourage exercise
D. Restrict oral fluids
2|Page
,Rationale: The manifestations are consistent with hypoglycemia. An
alert client who can swallow should receive rapidly absorbed
carbohydrate, followed by reassessment.
Question 5
A client with pneumonia has a respiratory rate of 30/min, oxygen
saturation of 89%, and increasing confusion. Which finding requires the
most immediate intervention?
A. Productive cough
B. Temperature of 38.1°C (100.6°F)
C. Oxygen saturation of 89% with confusion
D. Decreased appetite
Rationale: Hypoxemia accompanied by altered mental status indicates
impaired oxygenation and possible deterioration. Airway and
breathing take priority.
Question 6
A client reports crushing chest pain radiating to the left arm and is
diaphoretic. What should the nurse do first?
A. Provide a meal
B. Assess vital signs and initiate emergency cardiac assessment
C. Encourage ambulation
D. Place the client in a flat position
Rationale: The symptoms suggest acute coronary syndrome.
Immediate assessment, cardiac monitoring, and emergency
interventions are necessary.
3|Page
, Question 7
A client taking warfarin reports black, tarry stools. Which nursing action
is most appropriate?
A. Reassure the client that this is expected
B. Encourage increased vitamin K intake immediately
C. Assess for gastrointestinal bleeding and notify the provider
D. Administer the next dose early
Rationale: Black, tarry stools can indicate gastrointestinal bleeding.
Anticoagulated clients require prompt assessment and provider
notification.
Question 8
A client with chronic kidney disease has potassium of 6.3 mEq/L. Which
assessment finding is most concerning?
A. Dry skin
B. Fatigue
C. Cardiac dysrhythmia
D. Mild nausea
Rationale: Severe hyperkalemia can cause life-threatening cardiac
conduction abnormalities and dysrhythmias. Cardiac assessment and
monitoring are priorities.
Question 9
A client with a head injury becomes increasingly difficult to arouse and
develops unequal pupils. What should the nurse recognize?
4|Page
