NURS 103 Fundamentals of Nursing Exam 4 Study Guide 2026 |WCU
1. A nurse is reviewing the arterial blood gas (ABG) results of a patient with
chronic obstructive pulmonary disease (COPD). The results are: pH 7.28, PaCO2
52 mmHg, and HCO3 26 mEq/L. Which acid-base imbalance is the patient
experiencing?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Answer: B
Rationale: The pH is low (acidosis) and the PaCO2 is high (respiratory cause). The
bicarbonate is within or near normal limits, indicating a respiratory acidosis, commonly
seen in COPD patients due to CO2 retention.
2. A patient presents with a serum potassium level of 6.2 mEq/L. Which clinical
manifestation should the nurse prioritize for assessment?
A. Hyperactive bowel sounds
B. Cardiac dysrhythmias on the ECG
C. Increased muscle strength
D. Polyuria and thirst
Answer: B
Rationale: Hyperkalemia (potassium > 5.0 mEq/L) can cause life-threatening cardiac
dysrhythmias and EKG changes, such as peaked T waves or widened QRS complexes.
,3. While performing a wound assessment, the nurse notes that the wound bed
is covered with thick, yellow, stringy tissue. How should the nurse document
this finding?
A. Slough
B. Eschar
C. Granulation tissue
D. Epithelialization
Answer: A
Rationale: Slough is yellow, tan, or gray stringy tissue that is attached to the wound bed
and must be removed for the wound to heal.
4. The nurse is caring for a post-operative patient who suddenly develops sharp
chest pain and dyspnea. The patient’s oxygen saturation drops to 88%. What is
the nurse’s priority action?
A. Obtain an EKG immediately
B. Administer prescribed morphine for pain
C. Encourage the patient to use an incentive spirometer
D. Raise the head of the bed and apply oxygen
Answer: D
Rationale: These symptoms are suggestive of a pulmonary embolism. The immediate
priority is to improve oxygenation and respiratory effort by positioning the patient upright
and providing supplemental oxygen.
, 5. A nurse is preparing to administer an intermittent enteral feeding through a
nasogastric (NG) tube. What is the most reliable bedside method to confirm the
tube’s position before feeding?
A. Asking the patient to speak and cough
B. Auscultating for a ‘whoosh’ sound while injecting air
C. Checking the marking on the tube at the naris
D. Aspirating gastric contents and checking the pH
Answer: D
Rationale: While X-ray is the gold standard for initial placement, checking the pH of
aspirate (usually <5 for gastric) is the most reliable bedside method. Auscultation is no
longer considered evidence-based for placement confirmation.
6. Which assessment finding in a patient with an indwelling urinary catheter
requires immediate intervention?
A. The urine in the tubing is dark amber
B. The collection bag contains 150 mL of urine after 4 hours
C. The patient complains of a constant urge to void
D. The drainage bag is hanging on the side rail of the bed
Answer: D
Rationale: The drainage bag must never be attached to the side rail because it can be
raised above the level of the bladder, causing reflux of urine and increasing the risk of
infection. It should be attached to the bed frame.
1. A nurse is reviewing the arterial blood gas (ABG) results of a patient with
chronic obstructive pulmonary disease (COPD). The results are: pH 7.28, PaCO2
52 mmHg, and HCO3 26 mEq/L. Which acid-base imbalance is the patient
experiencing?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Answer: B
Rationale: The pH is low (acidosis) and the PaCO2 is high (respiratory cause). The
bicarbonate is within or near normal limits, indicating a respiratory acidosis, commonly
seen in COPD patients due to CO2 retention.
2. A patient presents with a serum potassium level of 6.2 mEq/L. Which clinical
manifestation should the nurse prioritize for assessment?
A. Hyperactive bowel sounds
B. Cardiac dysrhythmias on the ECG
C. Increased muscle strength
D. Polyuria and thirst
Answer: B
Rationale: Hyperkalemia (potassium > 5.0 mEq/L) can cause life-threatening cardiac
dysrhythmias and EKG changes, such as peaked T waves or widened QRS complexes.
,3. While performing a wound assessment, the nurse notes that the wound bed
is covered with thick, yellow, stringy tissue. How should the nurse document
this finding?
A. Slough
B. Eschar
C. Granulation tissue
D. Epithelialization
Answer: A
Rationale: Slough is yellow, tan, or gray stringy tissue that is attached to the wound bed
and must be removed for the wound to heal.
4. The nurse is caring for a post-operative patient who suddenly develops sharp
chest pain and dyspnea. The patient’s oxygen saturation drops to 88%. What is
the nurse’s priority action?
A. Obtain an EKG immediately
B. Administer prescribed morphine for pain
C. Encourage the patient to use an incentive spirometer
D. Raise the head of the bed and apply oxygen
Answer: D
Rationale: These symptoms are suggestive of a pulmonary embolism. The immediate
priority is to improve oxygenation and respiratory effort by positioning the patient upright
and providing supplemental oxygen.
, 5. A nurse is preparing to administer an intermittent enteral feeding through a
nasogastric (NG) tube. What is the most reliable bedside method to confirm the
tube’s position before feeding?
A. Asking the patient to speak and cough
B. Auscultating for a ‘whoosh’ sound while injecting air
C. Checking the marking on the tube at the naris
D. Aspirating gastric contents and checking the pH
Answer: D
Rationale: While X-ray is the gold standard for initial placement, checking the pH of
aspirate (usually <5 for gastric) is the most reliable bedside method. Auscultation is no
longer considered evidence-based for placement confirmation.
6. Which assessment finding in a patient with an indwelling urinary catheter
requires immediate intervention?
A. The urine in the tubing is dark amber
B. The collection bag contains 150 mL of urine after 4 hours
C. The patient complains of a constant urge to void
D. The drainage bag is hanging on the side rail of the bed
Answer: D
Rationale: The drainage bag must never be attached to the side rail because it can be
raised above the level of the bladder, causing reflux of urine and increasing the risk of
infection. It should be attached to the bed frame.
