BSN3A NCLEX-RN Preparation
Assessment Practice Questions &
[Verified Answers], Plus Explained
Rationales|2026 Latest Update| Instant
Download PDF
1. A nurse is caring for a client who has a potassium level of 2.8
mEq/L. Which finding should the nurse anticipate?
A. Hyperactive bowel sounds
B. Muscle weakness
C. Bounding peripheral pulses
D. Increased deep tendon reflexes
Rationale: Hypokalemia can cause muscle weakness, fatigue, cardiac
dysrhythmias, and decreased gastrointestinal motility. A potassium
level below approximately 3.5 mEq/L is considered low.
2. A client with heart failure is prescribed furosemide. Which
laboratory value is most important for the nurse to monitor?
A. Hemoglobin
B. Platelet count
C. Serum potassium
D. Serum amylase
1|Page
,Rationale: Furosemide is a loop diuretic that can cause significant
potassium loss. Monitoring serum potassium helps identify
hypokalemia and reduce the risk of cardiac dysrhythmias.
3. A nurse is assessing a client experiencing hypoglycemia. Which
finding is most likely?
A. Warm, dry skin
B. Bradycardia
C. Diaphoresis and tremors
D. Increased thirst and polyuria
Rationale: Hypoglycemia stimulates the sympathetic nervous system,
producing manifestations such as sweating, tremors, palpitations,
anxiety, and hunger.
4. A client with diabetes mellitus is awake and has a blood glucose
level of 52 mg/dL. What should the nurse do first?
A. Administer regular insulin
B. Start an IV insulin infusion
C. Give approximately 15 g of rapid-acting carbohydrate
D. Encourage the client to exercise
Rationale: An alert client who can safely swallow should receive
approximately 15 g of rapid-acting carbohydrate, followed by
reassessment of glucose. Exercise and insulin would worsen
hypoglycemia.
2|Page
,5. A client receiving morphine develops a respiratory rate of 8/min
and is difficult to arouse. Which medication should the nurse
anticipate administering?
A. Flumazenil
B. Atropine
C. Naloxone
D. Protamine sulfate
Rationale: Naloxone is an opioid antagonist used to reverse opioid-
induced respiratory and central nervous system depression. The client
also requires immediate airway and respiratory support.
6. A nurse is caring for a client with suspected increased intracranial
pressure. Which assessment finding requires immediate attention?
A. Mild headache
B. Photophobia
C. Decreasing level of consciousness
D. Occasional nausea
Rationale: A declining level of consciousness is an important sign of
worsening neurologic status and potentially increasing intracranial
pressure. Prompt intervention is necessary.
7. A client with chronic obstructive pulmonary disease is receiving
oxygen. Which nursing intervention is appropriate?
A. Maintain oxygen saturation at 100%
B. Administer oxygen at the highest possible flow rate
C. Use the lowest oxygen concentration necessary to achieve the
3|Page
, prescribed target
D. Withhold oxygen because it suppresses breathing
Rationale: Clients with COPD may require controlled oxygen therapy.
Oxygen should be titrated according to the prescribed target and the
client's clinical condition rather than automatically using high
concentrations.
8. A postoperative client suddenly develops shortness of breath, chest
pain, tachycardia, and anxiety. Which complication should the nurse
suspect?
A. Atelectasis
B. Pneumonia
C. Pulmonary embolism
D. Fluid overload
Rationale: Sudden dyspnea, pleuritic chest discomfort, tachycardia,
and anxiety are classic warning signs of pulmonary embolism. This is a
potentially life-threatening emergency.
9. Which intervention is most appropriate for preventing
postoperative deep-vein thrombosis?
A. Restricting oral fluids
B. Maintaining strict bed rest
C. Encouraging early ambulation as prescribed
D. Applying heat directly to the calves
Rationale: Early ambulation promotes venous circulation and
decreases venous stasis, reducing the risk of DVT. Other preventive
4|Page
Assessment Practice Questions &
[Verified Answers], Plus Explained
Rationales|2026 Latest Update| Instant
Download PDF
1. A nurse is caring for a client who has a potassium level of 2.8
mEq/L. Which finding should the nurse anticipate?
A. Hyperactive bowel sounds
B. Muscle weakness
C. Bounding peripheral pulses
D. Increased deep tendon reflexes
Rationale: Hypokalemia can cause muscle weakness, fatigue, cardiac
dysrhythmias, and decreased gastrointestinal motility. A potassium
level below approximately 3.5 mEq/L is considered low.
2. A client with heart failure is prescribed furosemide. Which
laboratory value is most important for the nurse to monitor?
A. Hemoglobin
B. Platelet count
C. Serum potassium
D. Serum amylase
1|Page
,Rationale: Furosemide is a loop diuretic that can cause significant
potassium loss. Monitoring serum potassium helps identify
hypokalemia and reduce the risk of cardiac dysrhythmias.
3. A nurse is assessing a client experiencing hypoglycemia. Which
finding is most likely?
A. Warm, dry skin
B. Bradycardia
C. Diaphoresis and tremors
D. Increased thirst and polyuria
Rationale: Hypoglycemia stimulates the sympathetic nervous system,
producing manifestations such as sweating, tremors, palpitations,
anxiety, and hunger.
4. A client with diabetes mellitus is awake and has a blood glucose
level of 52 mg/dL. What should the nurse do first?
A. Administer regular insulin
B. Start an IV insulin infusion
C. Give approximately 15 g of rapid-acting carbohydrate
D. Encourage the client to exercise
Rationale: An alert client who can safely swallow should receive
approximately 15 g of rapid-acting carbohydrate, followed by
reassessment of glucose. Exercise and insulin would worsen
hypoglycemia.
2|Page
,5. A client receiving morphine develops a respiratory rate of 8/min
and is difficult to arouse. Which medication should the nurse
anticipate administering?
A. Flumazenil
B. Atropine
C. Naloxone
D. Protamine sulfate
Rationale: Naloxone is an opioid antagonist used to reverse opioid-
induced respiratory and central nervous system depression. The client
also requires immediate airway and respiratory support.
6. A nurse is caring for a client with suspected increased intracranial
pressure. Which assessment finding requires immediate attention?
A. Mild headache
B. Photophobia
C. Decreasing level of consciousness
D. Occasional nausea
Rationale: A declining level of consciousness is an important sign of
worsening neurologic status and potentially increasing intracranial
pressure. Prompt intervention is necessary.
7. A client with chronic obstructive pulmonary disease is receiving
oxygen. Which nursing intervention is appropriate?
A. Maintain oxygen saturation at 100%
B. Administer oxygen at the highest possible flow rate
C. Use the lowest oxygen concentration necessary to achieve the
3|Page
, prescribed target
D. Withhold oxygen because it suppresses breathing
Rationale: Clients with COPD may require controlled oxygen therapy.
Oxygen should be titrated according to the prescribed target and the
client's clinical condition rather than automatically using high
concentrations.
8. A postoperative client suddenly develops shortness of breath, chest
pain, tachycardia, and anxiety. Which complication should the nurse
suspect?
A. Atelectasis
B. Pneumonia
C. Pulmonary embolism
D. Fluid overload
Rationale: Sudden dyspnea, pleuritic chest discomfort, tachycardia,
and anxiety are classic warning signs of pulmonary embolism. This is a
potentially life-threatening emergency.
9. Which intervention is most appropriate for preventing
postoperative deep-vein thrombosis?
A. Restricting oral fluids
B. Maintaining strict bed rest
C. Encouraging early ambulation as prescribed
D. Applying heat directly to the calves
Rationale: Early ambulation promotes venous circulation and
decreases venous stasis, reducing the risk of DVT. Other preventive
4|Page
