BSN Clinical Judgment Examination
Practice Questions & [Verified Answers],
Plus Explained Rationales|2026 Latest
Update| Instant Download PDF
Question 1
A nurse is caring for a patient admitted with pneumonia who suddenly
becomes restless and confused. The patient's respiratory rate is
30/min, oxygen saturation is 88% on room air, and heart rate is
112/min. Which action should the nurse take first?
A. Notify the healthcare provider
B. Apply supplemental oxygen
C. Obtain a complete blood count
D. Administer the prescribed antibiotic
Answer: B. Apply supplemental oxygen
Rationale: The patient's restlessness, tachypnea, tachycardia, and
oxygen saturation of 88% indicate impaired oxygenation. Applying
supplemental oxygen addresses the immediate physiologic problem.
The nurse should then reassess the patient and escalate care as
indicated.
Question 2
A patient with heart failure reports increasing shortness of breath and
difficulty sleeping flat. The nurse notes bilateral crackles and 3+ lower-
1|Page
,extremity edema. Which finding is most important for the nurse to
recognize?
A. Increased fluid volume
B. Activity intolerance
C. Impaired oxygenation
D. Disturbed sleep pattern
Answer: C. Impaired oxygenation
Rationale: Crackles, orthopnea, dyspnea, and significant edema
suggest worsening heart failure with pulmonary congestion. Impaired
oxygenation is the priority because airway, breathing, and circulation
problems take precedence over secondary concerns.
Question 3
A patient with diabetes mellitus is receiving insulin. Thirty minutes
later, the patient becomes diaphoretic, shaky, and confused. What
should the nurse do first?
A. Administer the scheduled insulin
B. Check the patient's blood glucose level
C. Encourage the patient to ambulate
D. Administer the patient's next meal
Answer: B. Check the patient's blood glucose level
Rationale: Diaphoresis, tremors, and confusion are classic
manifestations of hypoglycemia. The nurse should immediately assess
the blood glucose level and, if hypoglycemia is confirmed or strongly
suspected, provide rapid-acting carbohydrate according to the
patient's condition and protocol.
2|Page
,Question 4
A postoperative patient reports severe abdominal pain. The nurse
observes abdominal rigidity, increasing heart rate, and a decreasing
blood pressure. Which complication should the nurse suspect?
A. Constipation
B. Surgical site infection
C. Internal bleeding or peritonitis
D. Expected postoperative discomfort
Answer: C. Internal bleeding or peritonitis
Rationale: Severe pain accompanied by abdominal rigidity,
tachycardia, and hypotension is concerning for a serious intra-
abdominal complication such as hemorrhage or peritonitis. This
requires immediate assessment and intervention rather than routine
postoperative pain management.
Question 5
A patient with chronic obstructive pulmonary disease is receiving
oxygen. The patient becomes increasingly drowsy and difficult to
arouse. Which assessment is most important?
A. Skin temperature
B. Respiratory status and level of consciousness
C. Urine color
D. Bowel sounds
Answer: B. Respiratory status and level of consciousness
Rationale: Increasing drowsiness in a patient with COPD may indicate
worsening hypercapnia or respiratory failure. Respiratory rate, depth,
3|Page
, oxygenation, ventilation, and mental status should be assessed
immediately.
Question 6
A nurse receives handoff on four patients. Which patient should the
nurse assess first?
A. A patient with chronic arthritis reporting pain of 6/10
B. A patient awaiting discharge instructions
C. A patient with asthma who has audible stridor
D. A patient requesting assistance with bathing
Answer: C. A patient with asthma who has audible stridor
Rationale: Stridor indicates significant upper-airway obstruction and
can rapidly progress to respiratory failure. This patient has an
immediate airway threat and takes priority over pain, discharge
teaching, and hygiene needs.
Question 7
A patient receiving a blood transfusion develops chills, fever, and low
back pain 15 minutes after the transfusion begins. What is the nurse's
priority action?
A. Slow the transfusion
B. Stop the transfusion immediately
C. Administer acetaminophen
D. Continue the transfusion and reassess in 15 minutes
Answer: B. Stop the transfusion immediately
4|Page
Practice Questions & [Verified Answers],
Plus Explained Rationales|2026 Latest
Update| Instant Download PDF
Question 1
A nurse is caring for a patient admitted with pneumonia who suddenly
becomes restless and confused. The patient's respiratory rate is
30/min, oxygen saturation is 88% on room air, and heart rate is
112/min. Which action should the nurse take first?
A. Notify the healthcare provider
B. Apply supplemental oxygen
C. Obtain a complete blood count
D. Administer the prescribed antibiotic
Answer: B. Apply supplemental oxygen
Rationale: The patient's restlessness, tachypnea, tachycardia, and
oxygen saturation of 88% indicate impaired oxygenation. Applying
supplemental oxygen addresses the immediate physiologic problem.
The nurse should then reassess the patient and escalate care as
indicated.
Question 2
A patient with heart failure reports increasing shortness of breath and
difficulty sleeping flat. The nurse notes bilateral crackles and 3+ lower-
1|Page
,extremity edema. Which finding is most important for the nurse to
recognize?
A. Increased fluid volume
B. Activity intolerance
C. Impaired oxygenation
D. Disturbed sleep pattern
Answer: C. Impaired oxygenation
Rationale: Crackles, orthopnea, dyspnea, and significant edema
suggest worsening heart failure with pulmonary congestion. Impaired
oxygenation is the priority because airway, breathing, and circulation
problems take precedence over secondary concerns.
Question 3
A patient with diabetes mellitus is receiving insulin. Thirty minutes
later, the patient becomes diaphoretic, shaky, and confused. What
should the nurse do first?
A. Administer the scheduled insulin
B. Check the patient's blood glucose level
C. Encourage the patient to ambulate
D. Administer the patient's next meal
Answer: B. Check the patient's blood glucose level
Rationale: Diaphoresis, tremors, and confusion are classic
manifestations of hypoglycemia. The nurse should immediately assess
the blood glucose level and, if hypoglycemia is confirmed or strongly
suspected, provide rapid-acting carbohydrate according to the
patient's condition and protocol.
2|Page
,Question 4
A postoperative patient reports severe abdominal pain. The nurse
observes abdominal rigidity, increasing heart rate, and a decreasing
blood pressure. Which complication should the nurse suspect?
A. Constipation
B. Surgical site infection
C. Internal bleeding or peritonitis
D. Expected postoperative discomfort
Answer: C. Internal bleeding or peritonitis
Rationale: Severe pain accompanied by abdominal rigidity,
tachycardia, and hypotension is concerning for a serious intra-
abdominal complication such as hemorrhage or peritonitis. This
requires immediate assessment and intervention rather than routine
postoperative pain management.
Question 5
A patient with chronic obstructive pulmonary disease is receiving
oxygen. The patient becomes increasingly drowsy and difficult to
arouse. Which assessment is most important?
A. Skin temperature
B. Respiratory status and level of consciousness
C. Urine color
D. Bowel sounds
Answer: B. Respiratory status and level of consciousness
Rationale: Increasing drowsiness in a patient with COPD may indicate
worsening hypercapnia or respiratory failure. Respiratory rate, depth,
3|Page
, oxygenation, ventilation, and mental status should be assessed
immediately.
Question 6
A nurse receives handoff on four patients. Which patient should the
nurse assess first?
A. A patient with chronic arthritis reporting pain of 6/10
B. A patient awaiting discharge instructions
C. A patient with asthma who has audible stridor
D. A patient requesting assistance with bathing
Answer: C. A patient with asthma who has audible stridor
Rationale: Stridor indicates significant upper-airway obstruction and
can rapidly progress to respiratory failure. This patient has an
immediate airway threat and takes priority over pain, discharge
teaching, and hygiene needs.
Question 7
A patient receiving a blood transfusion develops chills, fever, and low
back pain 15 minutes after the transfusion begins. What is the nurse's
priority action?
A. Slow the transfusion
B. Stop the transfusion immediately
C. Administer acetaminophen
D. Continue the transfusion and reassess in 15 minutes
Answer: B. Stop the transfusion immediately
4|Page
