BSN3A Nursing Clinical Assessment
Practice Questions & [Verified Answers],
Plus Explained Rationales|2026 Latest
Update| Instant Download PDF
1. A nurse is performing an initial assessment of a newly admitted
patient. Which action should the nurse perform first?
A. Review the patient's laboratory results
B. Assess airway, breathing, and circulation
C. Obtain the patient's complete medical history
D. Document the patient's medication list
Rationale: Airway, breathing, and circulation are immediate priorities
because compromise in any of these systems can rapidly become life-
threatening. The nurse should address physiologic stability before
completing a comprehensive assessment.
2. Which finding during a respiratory assessment requires the
nurse's immediate attention?
A. Respiratory rate of 18/min
B. Clear bilateral breath sounds
C. Inspiratory stridor
D. Oxygen saturation of 97%
Rationale: Inspiratory stridor indicates upper-airway obstruction and
can progress rapidly to respiratory failure. Immediate assessment and
intervention are required.
3. When assessing a patient's level of consciousness, which finding
indicates the greatest impairment?
1|Page
,A. Alert and oriented
B. Drowsy but easily aroused
C. Responds to verbal stimuli
D. Responds only to painful stimuli
Rationale: A patient who responds only to painful stimuli has a
significantly decreased level of consciousness and requires prompt
neurologic assessment.
4. A nurse is assessing peripheral circulation. Which finding is most
concerning?
A. Capillary refill of 2 seconds
B. Warm extremities
C. Palpable radial pulses
D. Absent pedal pulse in an affected extremity
Rationale: An absent peripheral pulse may indicate impaired arterial
circulation and potentially limb-threatening ischemia.
5. Which assessment technique should the nurse use first when
assessing the abdomen?
A. Palpation
B. Percussion
C. Inspection
D. Deep palpation
Rationale: Abdominal assessment follows the sequence of inspection,
auscultation, percussion, and palpation. Palpation before auscultation
may alter bowel sounds.
6. A patient reports sudden severe chest pain. Which assessment
finding is most important for the nurse to obtain immediately?
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,A. Dietary history
B. Family history
C. Vital signs and oxygen saturation
D. Previous surgical history
Rationale: Vital signs and oxygen saturation provide immediate
information about the patient's physiologic stability and help identify
potential cardiovascular or respiratory compromise.
7. Which finding is considered an objective assessment finding?
A. "I feel dizzy."
B. "My pain is severe."
C. "I feel nauseated."
D. Blood pressure of 88/54 mmHg
Rationale: Objective data are measurable or observable findings
obtained by the nurse, such as blood pressure, temperature, pulse,
and physical examination findings.
8. Which statement represents subjective data?
A. Pulse is 110/min
B. Skin is pale
C. Temperature is 38.5°C
D. "I feel short of breath."
Rationale: Subjective data are symptoms or experiences reported by
the patient that cannot be directly measured by the nurse.
9. A nurse is assessing a patient's pain. Which question is most
appropriate?
A. "You aren't having much pain, are you?"
B. "Does your pain seem serious?"
3|Page
, C. "Can you describe what your pain feels like?"
D. "Is your pain caused by your medication?"
Rationale: Open-ended questions allow the patient to describe the
quality and characteristics of pain without leading or influencing the
response.
10. Which assessment finding is most consistent with
hypovolemia?
A. Bounding pulse
B. Hypertension
C. Tachycardia and hypotension
D. Bradycardia and hypertension
Rationale: Loss of circulating volume commonly produces
compensatory tachycardia and, when significant, hypotension. Other
findings may include poor skin turgor and decreased urine output.
11. A nurse is assessing a patient with suspected infection.
Which combination of findings should raise the greatest concern
for systemic infection?
A. Temperature 36.8°C and pulse 72/min
B. Fever, tachycardia, tachypnea, and altered mental status
C. Mild fatigue and normal blood pressure
D. Localized redness without systemic symptoms
Rationale: Fever or hypothermia combined with tachycardia,
tachypnea, and altered mental status can indicate systemic infection
and possible sepsis.
12. Which finding should the nurse document as a normal adult
respiratory assessment?
4|Page
Practice Questions & [Verified Answers],
Plus Explained Rationales|2026 Latest
Update| Instant Download PDF
1. A nurse is performing an initial assessment of a newly admitted
patient. Which action should the nurse perform first?
A. Review the patient's laboratory results
B. Assess airway, breathing, and circulation
C. Obtain the patient's complete medical history
D. Document the patient's medication list
Rationale: Airway, breathing, and circulation are immediate priorities
because compromise in any of these systems can rapidly become life-
threatening. The nurse should address physiologic stability before
completing a comprehensive assessment.
2. Which finding during a respiratory assessment requires the
nurse's immediate attention?
A. Respiratory rate of 18/min
B. Clear bilateral breath sounds
C. Inspiratory stridor
D. Oxygen saturation of 97%
Rationale: Inspiratory stridor indicates upper-airway obstruction and
can progress rapidly to respiratory failure. Immediate assessment and
intervention are required.
3. When assessing a patient's level of consciousness, which finding
indicates the greatest impairment?
1|Page
,A. Alert and oriented
B. Drowsy but easily aroused
C. Responds to verbal stimuli
D. Responds only to painful stimuli
Rationale: A patient who responds only to painful stimuli has a
significantly decreased level of consciousness and requires prompt
neurologic assessment.
4. A nurse is assessing peripheral circulation. Which finding is most
concerning?
A. Capillary refill of 2 seconds
B. Warm extremities
C. Palpable radial pulses
D. Absent pedal pulse in an affected extremity
Rationale: An absent peripheral pulse may indicate impaired arterial
circulation and potentially limb-threatening ischemia.
5. Which assessment technique should the nurse use first when
assessing the abdomen?
A. Palpation
B. Percussion
C. Inspection
D. Deep palpation
Rationale: Abdominal assessment follows the sequence of inspection,
auscultation, percussion, and palpation. Palpation before auscultation
may alter bowel sounds.
6. A patient reports sudden severe chest pain. Which assessment
finding is most important for the nurse to obtain immediately?
2|Page
,A. Dietary history
B. Family history
C. Vital signs and oxygen saturation
D. Previous surgical history
Rationale: Vital signs and oxygen saturation provide immediate
information about the patient's physiologic stability and help identify
potential cardiovascular or respiratory compromise.
7. Which finding is considered an objective assessment finding?
A. "I feel dizzy."
B. "My pain is severe."
C. "I feel nauseated."
D. Blood pressure of 88/54 mmHg
Rationale: Objective data are measurable or observable findings
obtained by the nurse, such as blood pressure, temperature, pulse,
and physical examination findings.
8. Which statement represents subjective data?
A. Pulse is 110/min
B. Skin is pale
C. Temperature is 38.5°C
D. "I feel short of breath."
Rationale: Subjective data are symptoms or experiences reported by
the patient that cannot be directly measured by the nurse.
9. A nurse is assessing a patient's pain. Which question is most
appropriate?
A. "You aren't having much pain, are you?"
B. "Does your pain seem serious?"
3|Page
, C. "Can you describe what your pain feels like?"
D. "Is your pain caused by your medication?"
Rationale: Open-ended questions allow the patient to describe the
quality and characteristics of pain without leading or influencing the
response.
10. Which assessment finding is most consistent with
hypovolemia?
A. Bounding pulse
B. Hypertension
C. Tachycardia and hypotension
D. Bradycardia and hypertension
Rationale: Loss of circulating volume commonly produces
compensatory tachycardia and, when significant, hypotension. Other
findings may include poor skin turgor and decreased urine output.
11. A nurse is assessing a patient with suspected infection.
Which combination of findings should raise the greatest concern
for systemic infection?
A. Temperature 36.8°C and pulse 72/min
B. Fever, tachycardia, tachypnea, and altered mental status
C. Mild fatigue and normal blood pressure
D. Localized redness without systemic symptoms
Rationale: Fever or hypothermia combined with tachycardia,
tachypnea, and altered mental status can indicate systemic infection
and possible sepsis.
12. Which finding should the nurse document as a normal adult
respiratory assessment?
4|Page
