BSN Clinical Readiness Examination
Practice Questions & [Verified Answers],
Plus Explained Rationales|2026 Latest
Update| Instant Download PDF
1. A nurse is assessing a postoperative client 2 hours after
abdominal surgery. Which finding requires the nurse’s immediate
intervention?
A. Pain rated 6/10
B. Temperature of 37.4°C (99.3°F)
C. Urine output of 15 mL during the past hour
D. Small amount of serosanguineous drainage on the dressing
Answer: C. Urine output of 15 mL during the past hour
Rationale: Urine output below approximately 30 mL/hr in an adult
may indicate inadequate renal perfusion, hypovolemia, or another
complication. The nurse should promptly assess the client and notify
the appropriate provider based on findings.
2. A client with heart failure is receiving furosemide. Which
laboratory value is most important for the nurse to monitor?
A. Calcium
B. Potassium
C. Hemoglobin
D. Platelet count
Answer: B. Potassium
1|Page
,Rationale: Furosemide is a loop diuretic that can cause significant
potassium loss. Hypokalemia increases the risk of dysrhythmias and
requires prompt recognition and management.
3. A nurse is caring for a client receiving a continuous IV infusion of
heparin. Which laboratory test is commonly used to evaluate the
therapeutic effect of unfractionated heparin?
A. INR
B. aPTT
C. Hemoglobin A1c
D. Serum creatinine
Answer: B. aPTT
Rationale: The activated partial thromboplastin time (aPTT) is
commonly used to monitor unfractionated heparin therapy and guide
dosage adjustments according to institutional protocols.
4. A client with chronic obstructive pulmonary disease is receiving
oxygen therapy. Which nursing action is most appropriate?
A. Administer oxygen at the highest possible flow rate
B. Maintain oxygen at the prescribed target level
C. Discontinue oxygen if the respiratory rate decreases
D. Encourage the client to breathe rapidly and deeply
Answer: B. Maintain oxygen at the prescribed target level
Rationale: Oxygen should be titrated according to the prescription and
the client’s clinical status. Excessive oxygen administration in
susceptible clients can worsen hypercapnia, so controlled oxygen
therapy is appropriate.
5. A nurse is preparing to administer insulin lispro. When should the
nurse generally administer this medication?
2|Page
,A. About 30–60 minutes before meals
B. Immediately before or with a meal
C. At bedtime regardless of food intake
D. Two hours after meals
Answer: B. Immediately before or with a meal
Rationale: Insulin lispro is rapid acting and is generally administered
shortly before meals or with meals to correspond with the rise in
blood glucose from food intake.
6. A client reports crushing substernal chest pain radiating to the left
arm. Which action should the nurse take first?
A. Obtain a detailed dietary history
B. Encourage the client to ambulate
C. Assess vital signs and initiate immediate cardiac assessment
D. Provide a high-fat snack
Answer: C. Assess vital signs and initiate immediate cardiac
assessment
Rationale: Acute chest pain with radiation to the arm may indicate
acute coronary syndrome. Immediate assessment and rapid initiation
of appropriate emergency interventions are priorities.
7. A nurse enters a client’s room and finds the client unresponsive
and not breathing normally. What should the nurse do first?
A. Obtain a complete health history
B. Activate the emergency response system and begin CPR as indicated
C. Insert an indwelling urinary catheter
D. Obtain a routine temperature
Answer: B. Activate the emergency response system and begin CPR as
indicated
3|Page
, Rationale: An unresponsive client who is not breathing normally
requires immediate resuscitation. The nurse should activate
emergency assistance and initiate high-quality CPR according to
current resuscitation protocols.
8. A client with diabetes mellitus is awake, diaphoretic, shaky, and
has a blood glucose level of 52 mg/dL (2.9 mmol/L). What is the
priority intervention?
A. Administer rapid-acting carbohydrate
B. Administer long-acting insulin
C. Restrict oral fluids
D. Encourage exercise
Answer: A. Administer rapid-acting carbohydrate
Rationale: The symptoms are consistent with hypoglycemia. An alert
client who can safely swallow should receive a rapid source of glucose,
followed by reassessment of blood glucose.
9. Which assessment finding is most concerning in a client with a
suspected pulmonary embolism?
A. Mild nausea
B. Sudden dyspnea and chest pain
C. Increased appetite
D. Chronic joint stiffness
Answer: B. Sudden dyspnea and chest pain
Rationale: Sudden dyspnea, pleuritic chest pain, tachycardia, and
hypoxemia are classic concerning manifestations of pulmonary
embolism. Immediate assessment and emergency management are
required.
4|Page
Practice Questions & [Verified Answers],
Plus Explained Rationales|2026 Latest
Update| Instant Download PDF
1. A nurse is assessing a postoperative client 2 hours after
abdominal surgery. Which finding requires the nurse’s immediate
intervention?
A. Pain rated 6/10
B. Temperature of 37.4°C (99.3°F)
C. Urine output of 15 mL during the past hour
D. Small amount of serosanguineous drainage on the dressing
Answer: C. Urine output of 15 mL during the past hour
Rationale: Urine output below approximately 30 mL/hr in an adult
may indicate inadequate renal perfusion, hypovolemia, or another
complication. The nurse should promptly assess the client and notify
the appropriate provider based on findings.
2. A client with heart failure is receiving furosemide. Which
laboratory value is most important for the nurse to monitor?
A. Calcium
B. Potassium
C. Hemoglobin
D. Platelet count
Answer: B. Potassium
1|Page
,Rationale: Furosemide is a loop diuretic that can cause significant
potassium loss. Hypokalemia increases the risk of dysrhythmias and
requires prompt recognition and management.
3. A nurse is caring for a client receiving a continuous IV infusion of
heparin. Which laboratory test is commonly used to evaluate the
therapeutic effect of unfractionated heparin?
A. INR
B. aPTT
C. Hemoglobin A1c
D. Serum creatinine
Answer: B. aPTT
Rationale: The activated partial thromboplastin time (aPTT) is
commonly used to monitor unfractionated heparin therapy and guide
dosage adjustments according to institutional protocols.
4. A client with chronic obstructive pulmonary disease is receiving
oxygen therapy. Which nursing action is most appropriate?
A. Administer oxygen at the highest possible flow rate
B. Maintain oxygen at the prescribed target level
C. Discontinue oxygen if the respiratory rate decreases
D. Encourage the client to breathe rapidly and deeply
Answer: B. Maintain oxygen at the prescribed target level
Rationale: Oxygen should be titrated according to the prescription and
the client’s clinical status. Excessive oxygen administration in
susceptible clients can worsen hypercapnia, so controlled oxygen
therapy is appropriate.
5. A nurse is preparing to administer insulin lispro. When should the
nurse generally administer this medication?
2|Page
,A. About 30–60 minutes before meals
B. Immediately before or with a meal
C. At bedtime regardless of food intake
D. Two hours after meals
Answer: B. Immediately before or with a meal
Rationale: Insulin lispro is rapid acting and is generally administered
shortly before meals or with meals to correspond with the rise in
blood glucose from food intake.
6. A client reports crushing substernal chest pain radiating to the left
arm. Which action should the nurse take first?
A. Obtain a detailed dietary history
B. Encourage the client to ambulate
C. Assess vital signs and initiate immediate cardiac assessment
D. Provide a high-fat snack
Answer: C. Assess vital signs and initiate immediate cardiac
assessment
Rationale: Acute chest pain with radiation to the arm may indicate
acute coronary syndrome. Immediate assessment and rapid initiation
of appropriate emergency interventions are priorities.
7. A nurse enters a client’s room and finds the client unresponsive
and not breathing normally. What should the nurse do first?
A. Obtain a complete health history
B. Activate the emergency response system and begin CPR as indicated
C. Insert an indwelling urinary catheter
D. Obtain a routine temperature
Answer: B. Activate the emergency response system and begin CPR as
indicated
3|Page
, Rationale: An unresponsive client who is not breathing normally
requires immediate resuscitation. The nurse should activate
emergency assistance and initiate high-quality CPR according to
current resuscitation protocols.
8. A client with diabetes mellitus is awake, diaphoretic, shaky, and
has a blood glucose level of 52 mg/dL (2.9 mmol/L). What is the
priority intervention?
A. Administer rapid-acting carbohydrate
B. Administer long-acting insulin
C. Restrict oral fluids
D. Encourage exercise
Answer: A. Administer rapid-acting carbohydrate
Rationale: The symptoms are consistent with hypoglycemia. An alert
client who can safely swallow should receive a rapid source of glucose,
followed by reassessment of blood glucose.
9. Which assessment finding is most concerning in a client with a
suspected pulmonary embolism?
A. Mild nausea
B. Sudden dyspnea and chest pain
C. Increased appetite
D. Chronic joint stiffness
Answer: B. Sudden dyspnea and chest pain
Rationale: Sudden dyspnea, pleuritic chest pain, tachycardia, and
hypoxemia are classic concerning manifestations of pulmonary
embolism. Immediate assessment and emergency management are
required.
4|Page
