BSN3A Fundamentals of Nursing Exam Practice
Questions & [Verified Answers], Plus
Explained Rationales|2026 Latest Update|
Instant Download PDF
1. A nurse is preparing to assess a newly admitted client. Which
action should the nurse take first?
A. Obtain the client's complete medical history
B. Perform hand hygiene
C. Measure the client's weight
D. Review the medication administration record
Rationale: Hand hygiene is the first infection-prevention measure the
nurse should perform before interacting with the client. It reduces
transmission of microorganisms and should occur before and after
patient contact.
2. Which assessment finding requires the nurse's immediate
attention?
A. Temperature of 37.4°C (99.3°F)
B. Respiratory rate of 18/min
C. Oxygen saturation of 84%
D. Pulse rate of 88/min
Rationale: An oxygen saturation of 84% indicates significant
hypoxemia and requires immediate assessment and intervention.
Airway and breathing take priority under the ABC framework.
3. A nurse is repositioning an immobile client. Which intervention is
most effective for preventing pressure injuries?
1|Page
,A. Massage reddened areas
B. Keep the head of the bed elevated at all times
C. Reposition the client regularly and offload pressure areas
D. Apply powder to all skin folds
Rationale: Regular repositioning and pressure redistribution reduce
prolonged tissue compression and help prevent pressure injuries.
Massaging reddened areas can further damage tissue.
4. Which finding is most characteristic of a stage 1 pressure injury?
A. Full-thickness tissue loss
B. Exposed bone or tendon
C. Open blister with drainage
D. Intact skin with nonblanchable redness
Rationale: Stage 1 pressure injury is characterized by intact skin with
persistent, nonblanchable erythema over a pressure area.
5. Which action demonstrates proper use of standard precautions?
A. Wearing an N95 respirator for every client
B. Performing hand hygiene before and after client contact
C. Wearing sterile gloves for routine vital signs
D. Placing every client in isolation
Rationale: Standard precautions apply to all clients and include hand
hygiene and appropriate personal protective equipment based on
anticipated exposure to blood or body fluids.
6. A nurse is caring for a client with a suspected airborne infection.
Which personal protective equipment is appropriate?
A. Surgical mask only
B. Face shield only
2|Page
,C. Fit-tested N95 respirator or equivalent
D. Sterile gloves only
Rationale: Airborne precautions require respiratory protection such as
a fit-tested N95 respirator or equivalent, along with appropriate
environmental controls.
7. Which client should the nurse assess first?
A. A client requesting assistance with bathing
B. A client reporting mild incisional discomfort
C. A client with new-onset difficulty breathing
D. A client requesting discharge instructions
Rationale: New-onset difficulty breathing may indicate an airway or
respiratory emergency. The nurse should prioritize airway and
breathing before less urgent needs.
8. Which intervention is appropriate when transferring a client from
bed to a wheelchair?
A. Keep the wheelchair several feet from the bed
B. Lock the wheelchair brakes before transfer
C. Have the client stand before applying nonskid footwear
D. Pull the client by the arms
Rationale: Locking the wheelchair prevents movement during transfer
and reduces fall risk. Nonskid footwear and proper body mechanics
should also be used.
9. A nurse is teaching a client how to use an incentive spirometer.
Which instruction is correct?
A. Exhale forcefully into the device
B. Use the device only when short of breath
3|Page
, C. Inhale slowly and deeply through the mouthpiece
D. Breathe rapidly through the mouthpiece
Rationale: Incentive spirometry promotes lung expansion. The client
should inhale slowly and deeply through the mouthpiece and follow
prescribed repetition instructions.
10. Which nursing intervention best promotes adequate
oxygenation in a client experiencing dyspnea?
A. Place the client flat in bed
B. Restrict oral fluids for all clients
C. Position the client upright or in semi-Fowler's position
D. Encourage prolonged bed rest
Rationale: Upright positioning improves lung expansion and decreases
the work of breathing in many clients experiencing dyspnea.
11. A client reports pain rated 8/10. What should the nurse do
first?
A. Tell the client that pain is expected
B. Administer medication without further assessment
C. Perform a focused pain assessment
D. Ask the client's family to describe the pain
Rationale: Pain is subjective, so the nurse should assess location,
quality, intensity, timing, aggravating factors, and relieving factors
before implementing appropriate interventions.
12. Which statement about pain is correct?
A. Vital signs accurately determine pain intensity
B. Clients with chronic pain always appear uncomfortable
C. The client's self-report is the most reliable indicator of pain
D. Pain should be treated only when objective signs are present
4|Page
Questions & [Verified Answers], Plus
Explained Rationales|2026 Latest Update|
Instant Download PDF
1. A nurse is preparing to assess a newly admitted client. Which
action should the nurse take first?
A. Obtain the client's complete medical history
B. Perform hand hygiene
C. Measure the client's weight
D. Review the medication administration record
Rationale: Hand hygiene is the first infection-prevention measure the
nurse should perform before interacting with the client. It reduces
transmission of microorganisms and should occur before and after
patient contact.
2. Which assessment finding requires the nurse's immediate
attention?
A. Temperature of 37.4°C (99.3°F)
B. Respiratory rate of 18/min
C. Oxygen saturation of 84%
D. Pulse rate of 88/min
Rationale: An oxygen saturation of 84% indicates significant
hypoxemia and requires immediate assessment and intervention.
Airway and breathing take priority under the ABC framework.
3. A nurse is repositioning an immobile client. Which intervention is
most effective for preventing pressure injuries?
1|Page
,A. Massage reddened areas
B. Keep the head of the bed elevated at all times
C. Reposition the client regularly and offload pressure areas
D. Apply powder to all skin folds
Rationale: Regular repositioning and pressure redistribution reduce
prolonged tissue compression and help prevent pressure injuries.
Massaging reddened areas can further damage tissue.
4. Which finding is most characteristic of a stage 1 pressure injury?
A. Full-thickness tissue loss
B. Exposed bone or tendon
C. Open blister with drainage
D. Intact skin with nonblanchable redness
Rationale: Stage 1 pressure injury is characterized by intact skin with
persistent, nonblanchable erythema over a pressure area.
5. Which action demonstrates proper use of standard precautions?
A. Wearing an N95 respirator for every client
B. Performing hand hygiene before and after client contact
C. Wearing sterile gloves for routine vital signs
D. Placing every client in isolation
Rationale: Standard precautions apply to all clients and include hand
hygiene and appropriate personal protective equipment based on
anticipated exposure to blood or body fluids.
6. A nurse is caring for a client with a suspected airborne infection.
Which personal protective equipment is appropriate?
A. Surgical mask only
B. Face shield only
2|Page
,C. Fit-tested N95 respirator or equivalent
D. Sterile gloves only
Rationale: Airborne precautions require respiratory protection such as
a fit-tested N95 respirator or equivalent, along with appropriate
environmental controls.
7. Which client should the nurse assess first?
A. A client requesting assistance with bathing
B. A client reporting mild incisional discomfort
C. A client with new-onset difficulty breathing
D. A client requesting discharge instructions
Rationale: New-onset difficulty breathing may indicate an airway or
respiratory emergency. The nurse should prioritize airway and
breathing before less urgent needs.
8. Which intervention is appropriate when transferring a client from
bed to a wheelchair?
A. Keep the wheelchair several feet from the bed
B. Lock the wheelchair brakes before transfer
C. Have the client stand before applying nonskid footwear
D. Pull the client by the arms
Rationale: Locking the wheelchair prevents movement during transfer
and reduces fall risk. Nonskid footwear and proper body mechanics
should also be used.
9. A nurse is teaching a client how to use an incentive spirometer.
Which instruction is correct?
A. Exhale forcefully into the device
B. Use the device only when short of breath
3|Page
, C. Inhale slowly and deeply through the mouthpiece
D. Breathe rapidly through the mouthpiece
Rationale: Incentive spirometry promotes lung expansion. The client
should inhale slowly and deeply through the mouthpiece and follow
prescribed repetition instructions.
10. Which nursing intervention best promotes adequate
oxygenation in a client experiencing dyspnea?
A. Place the client flat in bed
B. Restrict oral fluids for all clients
C. Position the client upright or in semi-Fowler's position
D. Encourage prolonged bed rest
Rationale: Upright positioning improves lung expansion and decreases
the work of breathing in many clients experiencing dyspnea.
11. A client reports pain rated 8/10. What should the nurse do
first?
A. Tell the client that pain is expected
B. Administer medication without further assessment
C. Perform a focused pain assessment
D. Ask the client's family to describe the pain
Rationale: Pain is subjective, so the nurse should assess location,
quality, intensity, timing, aggravating factors, and relieving factors
before implementing appropriate interventions.
12. Which statement about pain is correct?
A. Vital signs accurately determine pain intensity
B. Clients with chronic pain always appear uncomfortable
C. The client's self-report is the most reliable indicator of pain
D. Pain should be treated only when objective signs are present
4|Page
