BSN3A NCLEX-Style Exam Review with Questions,
Answers and Rationales 2026/2027 Update
Section 1: Advanced Clinical Management & Pharmacology
Question 1
A nurse is caring for a client with acute decompensated heart failure who is receiving an
intravenous infusion of milrinone. The nurse understands that this medication belongs to which
pharmacological class and produces what primary physiological effect?
A. Phosphodiesterase inhibitor; provides positive inotropic action and smooth muscle
relaxation resulting in vasodilation
B. Beta-adrenergic antagonist; decreases myocardial contractility and slows atrioventricular
nodal conduction
C. Direct alpha-agonist; causes profound peripheral vasoconstriction to rapidly elevate
systemic blood pressure
D. Calcium channel blocker; inhibits transmembrane calcium influx to decrease heart rate
exclusively
Correct Answer: A. Phosphodiesterase inhibitor; provides positive inotropic action and
smooth muscle relaxation resulting in vasodilation
Rationale: Milrinone is a phosphodiesterase inhibitor that increases intracellular cyclic
adenosine monophosphate within myocardial and vascular tissues. This produces a dual effect:
positive inotropy (increasing myocardial contractility) and vasodilation (reducing both preload
and afterload), making it valuable in short-term management of acute heart failure.
Question 2
A nurse is monitoring a client receiving intravenous magnesium sulfate for the management of
severe preeclampsia. Which assessment finding indicates early magnesium toxicity requiring
immediate intervention?
A. Spontaneous urine output of sixty milliliters per hour
B. Absence of deep tendon reflexes
C. Clear breath sounds bilaterally with normal respiratory rate
, D. Blood pressure reading within the pre-established target range
Correct Answer: B. Absence of deep tendon reflexes
Rationale: The earliest clinical sign of rising serum magnesium levels and impending toxicity is
the depression and eventual loss of deep tendon reflexes. Monitoring patellar reflexes is a
mandatory nursing assessment during magnesium sulfate therapy. Calcium gluconate must be
readily available as the specific reversal antidote.
Question 3
A critical care nurse is reviewing the hemodynamic profile of a client in septic shock. Which
combination of parameters is characteristic of the hyperdynamic (warm) phase of septic shock?
A. Markedly elevated systemic vascular resistance, significantly reduced cardiac output, and
cool extremities
B. Elevated pulmonary artery wedge pressure with severely depressed stroke volume index
C. Decreased systemic vascular resistance, normal or increased cardiac output, and bounding
pulses
D. Normal systemic vascular resistance paired with profound bradycardia and bradypnea
Correct Answer: C. Decreased systemic vascular resistance, normal or increased cardiac
output, and bounding pulses
Rationale: Early septic shock is characterized by systemic vasodilation mediated by
inflammatory cytokines, leading to decreased systemic vascular resistance. To compensate, the
heart increases output, resulting in a hyperdynamic state marked by warm skin, bounding pulses,
and normal or elevated cardiac output before progressing to cold, decompensated shock.
Question 4
A nurse is providing discharge instructions to a client newly prescribed warfarin therapy
following mechanical heart valve replacement. Which statement by the client indicates an
accurate understanding of dietary and lifestyle modifications?
A. "I can safely take high-dose over-the-counter ibuprofen and aspirin whenever I experience
minor headaches or joint stiffness."
B. "I will discontinue taking my warfarin tablets immediately if my international normalized
ratio rises above baseline levels by even a small amount."
C. "I should double my next scheduled dose of warfarin if I realize I missed taking my
medication yesterday."
, D. "I need to maintain a consistent, moderate daily intake of green leafy vegetables rather
than completely eliminating them from my diet."
Correct Answer: D. "I need to maintain a consistent, moderate daily intake of green leafy
vegetables rather than completely eliminating them from my diet."
Rationale: Green leafy vegetables are rich in vitamin K, which antagonizes the anticoagulant
effects of warfarin. Complete elimination is unnecessary and can complicate stability; instead,
clients must keep their dietary vitamin K intake consistent. Non-steroidal anti-inflammatory
drugs like ibuprofen increase bleeding risks and must be avoided.
Question 5
A nurse is assessing a client with acute pancreatitis who reports severe, boring epigastric pain
radiating to the back. Which physical sign should the nurse look for that indicates retroperitoneal
hemorrhage?
A. McBurney sign and Rovsing sign
B. Murphy sign and Blumberg sign
C. Cullen sign and Turner sign
D. Trousseau sign and Chvostek sign
Correct Answer: C. Cullen sign and Turner sign
Rationale: Cullen sign (superficial edema and bruising around the umbilicus) and Turner sign
(bruising of the flanks) are clinical indicators of retroperitoneal hemorrhage resulting from
severe necrotizing pancreatitis, caused by blood tracking along fascial planes.
Section 2: Critical Care, Trauma, and Emergency Nursing
Question 6
An emergency department nurse is evaluating a client who sustained severe deceleration trauma
in a motor vehicle collision. The client presents with a widened mediastinum on chest
radiography, unequal upper extremity blood pulses, and tearing chest pain radiating to the back.
Which diagnosis is most likely?
A. Massive pulmonary thromboembolism
B. Acute thoracic aortic dissection
C. Acute anterior wall myocardial infarction
, D. Spontaneous tension pneumothorax
Correct Answer: B. Acute thoracic aortic dissection
Rationale: A widened mediastinum on chest X-ray combined with tearing chest or back pain
and pulse differentials between upper extremities is classic for acute thoracic aortic dissection.
This surgical emergency requires immediate blood pressure and heart rate control followed by
emergency repair.
Question 7
A critical care nurse is managing a mechanically ventilated client with acute respiratory distress
syndrome. The provider orders a trial of prone positioning. What is the primary physiological
rationale for placing this client in the prone position?
A. Prevention of hospital-acquired pressure injuries over the sacral prominence and heels
B. Facilitation of continuous enteral nutrition delivery without risk of aspiration
C. Recruitment of dorsal dependent lung units, improved ventilation-perfusion matching, and
enhanced oxygenation
D. Reduction of intra-abdominal pressure to improve systemic venous return and preload
Correct Answer: C. Recruitment of dorsal dependent lung units, improved ventilation-
perfusion matching, and enhanced oxygenation
Rationale: In acute respiratory distress syndrome, alveolar collapse and edema predominantly
affect dorsal lung regions. Prone positioning uses gravity to shift dependent densities, relieves
heart compression on posterior lung fields, recruits collapsed alveoli, and optimizes ventilation-
perfusion matching.
Question 8
A nurse is caring for a client with increased intracranial pressure following a traumatic brain
injury. The nurse observes abnormal posturing where the client's arms are adducted and flexed
with rigid internal rotation, and the legs are stiffly extended. How should the nurse document this
finding?
A. Decerebrate posturing
B. Flaccid paralysis
C. Decorticate rigidity
D. Opisthotonos positioning
Answers and Rationales 2026/2027 Update
Section 1: Advanced Clinical Management & Pharmacology
Question 1
A nurse is caring for a client with acute decompensated heart failure who is receiving an
intravenous infusion of milrinone. The nurse understands that this medication belongs to which
pharmacological class and produces what primary physiological effect?
A. Phosphodiesterase inhibitor; provides positive inotropic action and smooth muscle
relaxation resulting in vasodilation
B. Beta-adrenergic antagonist; decreases myocardial contractility and slows atrioventricular
nodal conduction
C. Direct alpha-agonist; causes profound peripheral vasoconstriction to rapidly elevate
systemic blood pressure
D. Calcium channel blocker; inhibits transmembrane calcium influx to decrease heart rate
exclusively
Correct Answer: A. Phosphodiesterase inhibitor; provides positive inotropic action and
smooth muscle relaxation resulting in vasodilation
Rationale: Milrinone is a phosphodiesterase inhibitor that increases intracellular cyclic
adenosine monophosphate within myocardial and vascular tissues. This produces a dual effect:
positive inotropy (increasing myocardial contractility) and vasodilation (reducing both preload
and afterload), making it valuable in short-term management of acute heart failure.
Question 2
A nurse is monitoring a client receiving intravenous magnesium sulfate for the management of
severe preeclampsia. Which assessment finding indicates early magnesium toxicity requiring
immediate intervention?
A. Spontaneous urine output of sixty milliliters per hour
B. Absence of deep tendon reflexes
C. Clear breath sounds bilaterally with normal respiratory rate
, D. Blood pressure reading within the pre-established target range
Correct Answer: B. Absence of deep tendon reflexes
Rationale: The earliest clinical sign of rising serum magnesium levels and impending toxicity is
the depression and eventual loss of deep tendon reflexes. Monitoring patellar reflexes is a
mandatory nursing assessment during magnesium sulfate therapy. Calcium gluconate must be
readily available as the specific reversal antidote.
Question 3
A critical care nurse is reviewing the hemodynamic profile of a client in septic shock. Which
combination of parameters is characteristic of the hyperdynamic (warm) phase of septic shock?
A. Markedly elevated systemic vascular resistance, significantly reduced cardiac output, and
cool extremities
B. Elevated pulmonary artery wedge pressure with severely depressed stroke volume index
C. Decreased systemic vascular resistance, normal or increased cardiac output, and bounding
pulses
D. Normal systemic vascular resistance paired with profound bradycardia and bradypnea
Correct Answer: C. Decreased systemic vascular resistance, normal or increased cardiac
output, and bounding pulses
Rationale: Early septic shock is characterized by systemic vasodilation mediated by
inflammatory cytokines, leading to decreased systemic vascular resistance. To compensate, the
heart increases output, resulting in a hyperdynamic state marked by warm skin, bounding pulses,
and normal or elevated cardiac output before progressing to cold, decompensated shock.
Question 4
A nurse is providing discharge instructions to a client newly prescribed warfarin therapy
following mechanical heart valve replacement. Which statement by the client indicates an
accurate understanding of dietary and lifestyle modifications?
A. "I can safely take high-dose over-the-counter ibuprofen and aspirin whenever I experience
minor headaches or joint stiffness."
B. "I will discontinue taking my warfarin tablets immediately if my international normalized
ratio rises above baseline levels by even a small amount."
C. "I should double my next scheduled dose of warfarin if I realize I missed taking my
medication yesterday."
, D. "I need to maintain a consistent, moderate daily intake of green leafy vegetables rather
than completely eliminating them from my diet."
Correct Answer: D. "I need to maintain a consistent, moderate daily intake of green leafy
vegetables rather than completely eliminating them from my diet."
Rationale: Green leafy vegetables are rich in vitamin K, which antagonizes the anticoagulant
effects of warfarin. Complete elimination is unnecessary and can complicate stability; instead,
clients must keep their dietary vitamin K intake consistent. Non-steroidal anti-inflammatory
drugs like ibuprofen increase bleeding risks and must be avoided.
Question 5
A nurse is assessing a client with acute pancreatitis who reports severe, boring epigastric pain
radiating to the back. Which physical sign should the nurse look for that indicates retroperitoneal
hemorrhage?
A. McBurney sign and Rovsing sign
B. Murphy sign and Blumberg sign
C. Cullen sign and Turner sign
D. Trousseau sign and Chvostek sign
Correct Answer: C. Cullen sign and Turner sign
Rationale: Cullen sign (superficial edema and bruising around the umbilicus) and Turner sign
(bruising of the flanks) are clinical indicators of retroperitoneal hemorrhage resulting from
severe necrotizing pancreatitis, caused by blood tracking along fascial planes.
Section 2: Critical Care, Trauma, and Emergency Nursing
Question 6
An emergency department nurse is evaluating a client who sustained severe deceleration trauma
in a motor vehicle collision. The client presents with a widened mediastinum on chest
radiography, unequal upper extremity blood pulses, and tearing chest pain radiating to the back.
Which diagnosis is most likely?
A. Massive pulmonary thromboembolism
B. Acute thoracic aortic dissection
C. Acute anterior wall myocardial infarction
, D. Spontaneous tension pneumothorax
Correct Answer: B. Acute thoracic aortic dissection
Rationale: A widened mediastinum on chest X-ray combined with tearing chest or back pain
and pulse differentials between upper extremities is classic for acute thoracic aortic dissection.
This surgical emergency requires immediate blood pressure and heart rate control followed by
emergency repair.
Question 7
A critical care nurse is managing a mechanically ventilated client with acute respiratory distress
syndrome. The provider orders a trial of prone positioning. What is the primary physiological
rationale for placing this client in the prone position?
A. Prevention of hospital-acquired pressure injuries over the sacral prominence and heels
B. Facilitation of continuous enteral nutrition delivery without risk of aspiration
C. Recruitment of dorsal dependent lung units, improved ventilation-perfusion matching, and
enhanced oxygenation
D. Reduction of intra-abdominal pressure to improve systemic venous return and preload
Correct Answer: C. Recruitment of dorsal dependent lung units, improved ventilation-
perfusion matching, and enhanced oxygenation
Rationale: In acute respiratory distress syndrome, alveolar collapse and edema predominantly
affect dorsal lung regions. Prone positioning uses gravity to shift dependent densities, relieves
heart compression on posterior lung fields, recruits collapsed alveoli, and optimizes ventilation-
perfusion matching.
Question 8
A nurse is caring for a client with increased intracranial pressure following a traumatic brain
injury. The nurse observes abnormal posturing where the client's arms are adducted and flexed
with rigid internal rotation, and the legs are stiffly extended. How should the nurse document this
finding?
A. Decerebrate posturing
B. Flaccid paralysis
C. Decorticate rigidity
D. Opisthotonos positioning
