BSN3A NCLEX-RN Preparation Assessment
Practice Questions & [Verified Answers], Plus
Explained Rationales | 2026/2027 Latest
Update | Instant Download PDF
1. The nurse is caring for a client with a new tracheostomy. Which task can the
nurse safely delegate to the unlicensed assistive personnel (UAP)?
A) Assess the site for redness or drainage
B) Suction the tracheostomy tube as needed
C) Perform routine oral care
D) Change the tracheostomy tube ties
Answer: C) Perform routine oral care
Rationale: The UAP can perform routine tasks like oral care, which is within their scope
of practice. Tasks requiring assessment, sterile technique (suctioning), or complex
procedures that could compromise the airway must be performed by licensed nursing
staff.
2. A nurse is caring for four clients. Which client should the nurse assess first?
A) A client with chronic arthritis reporting pain of 5/10
B) A client with pneumonia and oxygen saturation of 86%
C) A client requesting assistance with bathing
D) A client awaiting discharge instructions
Answer: B) A client with pneumonia and oxygen saturation of 86%
Rationale: An oxygen saturation of 86% indicates significant hypoxemia and represents
an immediate threat to airway and breathing. The nurse should prioritize this client
using the ABC (Airway, Breathing, Circulation) framework.
,3. The nurse is preparing to discharge a client with a new prescription for
enoxaparin. Which statement indicates the client understands the teaching?
A) "I will inject the medication into my deltoid muscle."
B) "I will massage the injection site after administration."
C) "I will inject the medication into the abdomen, at least 2 inches from the umbilicus."
D) "I will aspirate before injecting to check for blood return."
Answer: C) "I will inject the medication into the abdomen, at least 2 inches from
the umbilicus."
Rationale: Enoxaparin is administered subcutaneously in the abdomen, at least 2 inches
from the umbilicus. The site should not be massaged after injection to prevent bruising.
4. A nurse is caring for a client who has just been informed of a terminal diagnosis.
The client states, "This can't be happening to me. The lab tests must be wrong."
The nurse identifies that the client is demonstrating which stage of grief?
A) Anger
B) Bargaining
C) Denial
D) Acceptance
Answer: C) Denial
Rationale: The client's refusal to accept the diagnosis and questioning the validity of the
tests is a classic defense mechanism of denial. This is a common initial reaction when
coping with a new, life-altering diagnosis.
5. Which action best demonstrates the integration of nursing art and science?
A) Following the surgeon's orders without question
B) Ambulating the patient based on the unit's standard protocol
C) Reviewing the latest research on early postoperative ambulation while considering
the patient's pain level and preferences
D) Waiting until the patient requests to get out of bed
Answer: C) Reviewing the latest research on early postoperative ambulation while
considering the patient's pain level and preferences
,Rationale: Nursing is both an art and a science. The science involves the knowledge base
from research and evidence, while the art involves the compassionate, individualized
care provided to patients. This option demonstrates the integration of both by using
research evidence while considering the patient's unique situation.
6. A nurse is providing discharge instructions to a client with a history of falls.
Which intervention is most important to prevent future falls?
A) Install grab bars in the bathroom
B) Encourage the client to wear shoes with nonslip soles
C) Remove loose rugs from the home
D) All of the above
Answer: D) All of the above
Rationale: All of these interventions are important to reduce fall risk in the home
environment. A comprehensive approach to fall prevention includes environmental
modifications and safety education.
7. The nurse is caring for a patient who is postoperative day 1 following abdominal
surgery. Which action best demonstrates the integration of evidence-based
practice?
A) Following the surgeon's orders without question
B) Ambulating the patient based on the unit's standard protocol
C) Reviewing the latest research on early postoperative ambulation while considering
the patient's pain level and preferences
D) Waiting until the patient requests to get out of bed
Answer: C) Reviewing the latest research on early postoperative ambulation while
considering the patient's pain level and preferences
Rationale: Evidence-based practice integrates the best research evidence with clinical
expertise and patient preferences. This approach considers individual patient factors
while applying research findings.
, 8. The nurse is caring for a client who is 2 hours post-operative following a
hysterectomy. The client's vital signs are BP 98/62, HR 110, and the client reports
feeling dizzy and lightheaded. The nurse's priority action is to:
A) Reapply the abdominal dressing
B) Notify the healthcare provider immediately
C) Re-position the client to the left side
D) Increase the IV fluid rate
Answer: B) Notify the healthcare provider immediately
Rationale: The client is showing signs of hypovolemic shock (tachycardia, hypotension,
dizziness). A small amount of drainage on the dressing could indicate internal bleeding.
The nurse must recognize this change in status and activate the chain of command.
9. The nurse is preparing to administer a blood transfusion. Which finding requires
immediate action?
A) Blood pressure of 118/76 mmHg
B) Heart rate of 88 beats per minute
C) Respiratory rate of 28 breaths per minute with crackles auscultated
D) Report of mild itching at the IV site
Answer: C) Respiratory rate of 28 breaths per minute with crackles auscultated
Rationale: Crackles and tachypnea are classic signs of fluid volume overload, which can
lead to pulmonary edema, a life-threatening complication of rapid transfusion. This
must be reported to the provider immediately.
10. A client develops chills and dyspnea shortly after a blood transfusion begins.
What should the nurse do first?
A) Increase the transfusion rate
B) Continue the transfusion and reassess later
C) Stop the transfusion immediately
D) Give the patient food
Answer: C) Stop the transfusion immediately
Practice Questions & [Verified Answers], Plus
Explained Rationales | 2026/2027 Latest
Update | Instant Download PDF
1. The nurse is caring for a client with a new tracheostomy. Which task can the
nurse safely delegate to the unlicensed assistive personnel (UAP)?
A) Assess the site for redness or drainage
B) Suction the tracheostomy tube as needed
C) Perform routine oral care
D) Change the tracheostomy tube ties
Answer: C) Perform routine oral care
Rationale: The UAP can perform routine tasks like oral care, which is within their scope
of practice. Tasks requiring assessment, sterile technique (suctioning), or complex
procedures that could compromise the airway must be performed by licensed nursing
staff.
2. A nurse is caring for four clients. Which client should the nurse assess first?
A) A client with chronic arthritis reporting pain of 5/10
B) A client with pneumonia and oxygen saturation of 86%
C) A client requesting assistance with bathing
D) A client awaiting discharge instructions
Answer: B) A client with pneumonia and oxygen saturation of 86%
Rationale: An oxygen saturation of 86% indicates significant hypoxemia and represents
an immediate threat to airway and breathing. The nurse should prioritize this client
using the ABC (Airway, Breathing, Circulation) framework.
,3. The nurse is preparing to discharge a client with a new prescription for
enoxaparin. Which statement indicates the client understands the teaching?
A) "I will inject the medication into my deltoid muscle."
B) "I will massage the injection site after administration."
C) "I will inject the medication into the abdomen, at least 2 inches from the umbilicus."
D) "I will aspirate before injecting to check for blood return."
Answer: C) "I will inject the medication into the abdomen, at least 2 inches from
the umbilicus."
Rationale: Enoxaparin is administered subcutaneously in the abdomen, at least 2 inches
from the umbilicus. The site should not be massaged after injection to prevent bruising.
4. A nurse is caring for a client who has just been informed of a terminal diagnosis.
The client states, "This can't be happening to me. The lab tests must be wrong."
The nurse identifies that the client is demonstrating which stage of grief?
A) Anger
B) Bargaining
C) Denial
D) Acceptance
Answer: C) Denial
Rationale: The client's refusal to accept the diagnosis and questioning the validity of the
tests is a classic defense mechanism of denial. This is a common initial reaction when
coping with a new, life-altering diagnosis.
5. Which action best demonstrates the integration of nursing art and science?
A) Following the surgeon's orders without question
B) Ambulating the patient based on the unit's standard protocol
C) Reviewing the latest research on early postoperative ambulation while considering
the patient's pain level and preferences
D) Waiting until the patient requests to get out of bed
Answer: C) Reviewing the latest research on early postoperative ambulation while
considering the patient's pain level and preferences
,Rationale: Nursing is both an art and a science. The science involves the knowledge base
from research and evidence, while the art involves the compassionate, individualized
care provided to patients. This option demonstrates the integration of both by using
research evidence while considering the patient's unique situation.
6. A nurse is providing discharge instructions to a client with a history of falls.
Which intervention is most important to prevent future falls?
A) Install grab bars in the bathroom
B) Encourage the client to wear shoes with nonslip soles
C) Remove loose rugs from the home
D) All of the above
Answer: D) All of the above
Rationale: All of these interventions are important to reduce fall risk in the home
environment. A comprehensive approach to fall prevention includes environmental
modifications and safety education.
7. The nurse is caring for a patient who is postoperative day 1 following abdominal
surgery. Which action best demonstrates the integration of evidence-based
practice?
A) Following the surgeon's orders without question
B) Ambulating the patient based on the unit's standard protocol
C) Reviewing the latest research on early postoperative ambulation while considering
the patient's pain level and preferences
D) Waiting until the patient requests to get out of bed
Answer: C) Reviewing the latest research on early postoperative ambulation while
considering the patient's pain level and preferences
Rationale: Evidence-based practice integrates the best research evidence with clinical
expertise and patient preferences. This approach considers individual patient factors
while applying research findings.
, 8. The nurse is caring for a client who is 2 hours post-operative following a
hysterectomy. The client's vital signs are BP 98/62, HR 110, and the client reports
feeling dizzy and lightheaded. The nurse's priority action is to:
A) Reapply the abdominal dressing
B) Notify the healthcare provider immediately
C) Re-position the client to the left side
D) Increase the IV fluid rate
Answer: B) Notify the healthcare provider immediately
Rationale: The client is showing signs of hypovolemic shock (tachycardia, hypotension,
dizziness). A small amount of drainage on the dressing could indicate internal bleeding.
The nurse must recognize this change in status and activate the chain of command.
9. The nurse is preparing to administer a blood transfusion. Which finding requires
immediate action?
A) Blood pressure of 118/76 mmHg
B) Heart rate of 88 beats per minute
C) Respiratory rate of 28 breaths per minute with crackles auscultated
D) Report of mild itching at the IV site
Answer: C) Respiratory rate of 28 breaths per minute with crackles auscultated
Rationale: Crackles and tachypnea are classic signs of fluid volume overload, which can
lead to pulmonary edema, a life-threatening complication of rapid transfusion. This
must be reported to the provider immediately.
10. A client develops chills and dyspnea shortly after a blood transfusion begins.
What should the nurse do first?
A) Increase the transfusion rate
B) Continue the transfusion and reassess later
C) Stop the transfusion immediately
D) Give the patient food
Answer: C) Stop the transfusion immediately
