BSN3A NCLEX-RN Preparation Assessment Practice Questions & [Verified Answers], Plus Explained
Rationales | 2026 Latest Update | Instant Download PDF
Questions 1–200
1. A nurse is caring for a client who is 2 days post-op abdominal surgery. Which finding requires
immediate action?
A) Incisional pain rated 4/10
B) Temperature 99.2°F (37.3°C)
C) Wound dehiscence with bowel visible
D) Serosanguineous drainage on dressing
Answer C: Wound dehiscence with bowel visible
Rationale: Wound dehiscence with evisceration is a surgical emergency; cover with sterile saline-moistened
gauze.
2. A client with heart failure is prescribed furosemide. Which electrolyte imbalance should the nurse
monitor closely?
A) Hyperkalemia
B) Hypokalemia
C) Hypermagnesemia
D) Hypercalcemia
Answer B: Hypokalemia
Rationale: Furosemide is a loop diuretic that causes potassium wasting; monitor for hypokalemia.
3. Which delegation task is appropriate for a licensed practical nurse (LPN)?
A) Administering enteral tube feeding to a stable client
B) Developing the plan of care
C) Performing initial assessment on a new admission
D) Providing client education on insulin self-administration
Answer A: Administering enteral tube feeding to a stable client
,Rationale: LPNs can administer enteral feedings and medications to stable clients; RNs perform initial
assessments and teaching.
4. A client is admitted with an exacerbation of COPD. Which arterial blood gas (ABG) finding is
expected?
A) pH 7.38, PaCO₂ 40, HCO₃ 24
B) pH 7.30, PaCO₂ 55, HCO₃ 30
C) pH 7.48, PaCO₂ 30, HCO₃ 22
D) pH 7.42, PaCO₂ 38, HCO₃ 26
Answer B: pH 7.30, PaCO₂ 55, HCO₃ 30
Rationale: COPD causes respiratory acidosis with metabolic compensation (elevated HCO₃).
5. A nurse is preparing to administer digoxin to a client with heart failure. Which assessment finding
indicates digoxin toxicity?
A) Heart rate 72 bpm
B) Nausea, vomiting, and visual disturbances
C) Blood pressure 138/88 mmHg
D) Respiratory rate 16/min
Answer B: Nausea, vomiting, and visual disturbances
Rationale: Digoxin toxicity causes GI symptoms (nausea, vomiting), visual changes, and arrhythmias.
6. Which client is at highest risk for developing a pressure ulcer?
A) A client who ambulates with a walker
B) A bedridden client with urinary incontinence and poor nutrition
C) A client who uses a wheelchair independently
D) A client who is alert and oriented
Answer B: A bedridden client with urinary incontinence and poor nutrition
Rationale: Immobility, incontinence, and poor nutrition significantly increase pressure ulcer risk.
7. A nurse is providing care to a client with a tracheostomy. Which action is correct during
suctioning?
A) Apply suction only when withdrawing the catheter
,B) Apply suction when inserting the catheter
C) Suction for 30 seconds at a time
D) Hyperoxygenate after suctioning only
Answer A: Apply suction only when withdrawing the catheter
Rationale: Suction on withdrawal, not insertion, to prevent mucosal damage; limit to 10-15 seconds.
8. A client with diabetes is admitted with diabetic ketoacidosis (DKA). Which intervention is most
important initially?
A) Administer IV potassium
B) Initiate IV fluid resuscitation with 0.9% normal saline
C) Administer subcutaneous insulin
D) Administer sodium bicarbonate
Answer B: Initiate IV fluid resuscitation with 0.9% normal saline
Rationale: Fluid resuscitation is the first priority to restore intravascular volume and improve perfusion.
9. A nurse is caring for a client who is in restraints. Which action is appropriate?
A) Assess the client every 4 hours
B) Document behavioral interventions attempted before restraints
C) Leave the restraints in place for 24 hours
D) Apply restraints without a physician's order
Answer B: Document behavioral interventions attempted before restraints
Rationale: Restraints require a physician's order and documentation of less restrictive measures attempted.
10. A client is prescribed enoxaparin (Lovenox) for DVT prophylaxis. The nurse should administer
this medication by which route?
A) Oral
B) Intravenous
C) Subcutaneous
D) Intramuscular
Answer C: Subcutaneous
Rationale: Enoxaparin is administered subcutaneously in the abdomen.
, 11. A client with chest pain is prescribed nitroglycerin sublingual. Which instruction should the
nurse include?
A) Swallow the tablet with water
B) Take one tablet at the onset of chest pain; may repeat every 5 minutes up to 3 doses
C) Take with a full glass of milk
D) Take only when lying down
Answer B: Take one tablet at the onset of chest pain; may repeat every 5 minutes up to 3 doses
Rationale: Nitroglycerin is taken sublingually; if pain persists after 3 doses, seek emergency care.
12. A client is experiencing anaphylaxis after receiving penicillin. Which medication should the nurse
administer first?
A) Benadryl (diphenhydramine)
B) Solu-Medrol (methylprednisolone)
C) Epinephrine
D) Albuterol
Answer C: Epinephrine
Rationale: Epinephrine is the first-line treatment for anaphylaxis to reverse bronchospasm and
hypotension.
13. A nurse is performing a focused assessment on a client with a hip fracture. Which finding is most
concerning?
A) Pain at the fracture site
B) Shortening and external rotation of the leg
C) Absent dorsalis pedis pulse
D) Ecchymosis on the affected leg
Answer C: Absent dorsalis pedis pulse
Rationale: Absent distal pulse indicates vascular compromise; requires immediate notification.
14. A client with schizophrenia is prescribed haloperidol. Which side effect should the nurse monitor
for?
A) Weight loss
B) Extrapyramidal symptoms (EPS)
C) Hyperglycemia
Rationales | 2026 Latest Update | Instant Download PDF
Questions 1–200
1. A nurse is caring for a client who is 2 days post-op abdominal surgery. Which finding requires
immediate action?
A) Incisional pain rated 4/10
B) Temperature 99.2°F (37.3°C)
C) Wound dehiscence with bowel visible
D) Serosanguineous drainage on dressing
Answer C: Wound dehiscence with bowel visible
Rationale: Wound dehiscence with evisceration is a surgical emergency; cover with sterile saline-moistened
gauze.
2. A client with heart failure is prescribed furosemide. Which electrolyte imbalance should the nurse
monitor closely?
A) Hyperkalemia
B) Hypokalemia
C) Hypermagnesemia
D) Hypercalcemia
Answer B: Hypokalemia
Rationale: Furosemide is a loop diuretic that causes potassium wasting; monitor for hypokalemia.
3. Which delegation task is appropriate for a licensed practical nurse (LPN)?
A) Administering enteral tube feeding to a stable client
B) Developing the plan of care
C) Performing initial assessment on a new admission
D) Providing client education on insulin self-administration
Answer A: Administering enteral tube feeding to a stable client
,Rationale: LPNs can administer enteral feedings and medications to stable clients; RNs perform initial
assessments and teaching.
4. A client is admitted with an exacerbation of COPD. Which arterial blood gas (ABG) finding is
expected?
A) pH 7.38, PaCO₂ 40, HCO₃ 24
B) pH 7.30, PaCO₂ 55, HCO₃ 30
C) pH 7.48, PaCO₂ 30, HCO₃ 22
D) pH 7.42, PaCO₂ 38, HCO₃ 26
Answer B: pH 7.30, PaCO₂ 55, HCO₃ 30
Rationale: COPD causes respiratory acidosis with metabolic compensation (elevated HCO₃).
5. A nurse is preparing to administer digoxin to a client with heart failure. Which assessment finding
indicates digoxin toxicity?
A) Heart rate 72 bpm
B) Nausea, vomiting, and visual disturbances
C) Blood pressure 138/88 mmHg
D) Respiratory rate 16/min
Answer B: Nausea, vomiting, and visual disturbances
Rationale: Digoxin toxicity causes GI symptoms (nausea, vomiting), visual changes, and arrhythmias.
6. Which client is at highest risk for developing a pressure ulcer?
A) A client who ambulates with a walker
B) A bedridden client with urinary incontinence and poor nutrition
C) A client who uses a wheelchair independently
D) A client who is alert and oriented
Answer B: A bedridden client with urinary incontinence and poor nutrition
Rationale: Immobility, incontinence, and poor nutrition significantly increase pressure ulcer risk.
7. A nurse is providing care to a client with a tracheostomy. Which action is correct during
suctioning?
A) Apply suction only when withdrawing the catheter
,B) Apply suction when inserting the catheter
C) Suction for 30 seconds at a time
D) Hyperoxygenate after suctioning only
Answer A: Apply suction only when withdrawing the catheter
Rationale: Suction on withdrawal, not insertion, to prevent mucosal damage; limit to 10-15 seconds.
8. A client with diabetes is admitted with diabetic ketoacidosis (DKA). Which intervention is most
important initially?
A) Administer IV potassium
B) Initiate IV fluid resuscitation with 0.9% normal saline
C) Administer subcutaneous insulin
D) Administer sodium bicarbonate
Answer B: Initiate IV fluid resuscitation with 0.9% normal saline
Rationale: Fluid resuscitation is the first priority to restore intravascular volume and improve perfusion.
9. A nurse is caring for a client who is in restraints. Which action is appropriate?
A) Assess the client every 4 hours
B) Document behavioral interventions attempted before restraints
C) Leave the restraints in place for 24 hours
D) Apply restraints without a physician's order
Answer B: Document behavioral interventions attempted before restraints
Rationale: Restraints require a physician's order and documentation of less restrictive measures attempted.
10. A client is prescribed enoxaparin (Lovenox) for DVT prophylaxis. The nurse should administer
this medication by which route?
A) Oral
B) Intravenous
C) Subcutaneous
D) Intramuscular
Answer C: Subcutaneous
Rationale: Enoxaparin is administered subcutaneously in the abdomen.
, 11. A client with chest pain is prescribed nitroglycerin sublingual. Which instruction should the
nurse include?
A) Swallow the tablet with water
B) Take one tablet at the onset of chest pain; may repeat every 5 minutes up to 3 doses
C) Take with a full glass of milk
D) Take only when lying down
Answer B: Take one tablet at the onset of chest pain; may repeat every 5 minutes up to 3 doses
Rationale: Nitroglycerin is taken sublingually; if pain persists after 3 doses, seek emergency care.
12. A client is experiencing anaphylaxis after receiving penicillin. Which medication should the nurse
administer first?
A) Benadryl (diphenhydramine)
B) Solu-Medrol (methylprednisolone)
C) Epinephrine
D) Albuterol
Answer C: Epinephrine
Rationale: Epinephrine is the first-line treatment for anaphylaxis to reverse bronchospasm and
hypotension.
13. A nurse is performing a focused assessment on a client with a hip fracture. Which finding is most
concerning?
A) Pain at the fracture site
B) Shortening and external rotation of the leg
C) Absent dorsalis pedis pulse
D) Ecchymosis on the affected leg
Answer C: Absent dorsalis pedis pulse
Rationale: Absent distal pulse indicates vascular compromise; requires immediate notification.
14. A client with schizophrenia is prescribed haloperidol. Which side effect should the nurse monitor
for?
A) Weight loss
B) Extrapyramidal symptoms (EPS)
C) Hyperglycemia
