NURS 103 | Fundamentals of Nursing | Actual Exam 4 | 2026/2027
Update WCU
1. A nurse is caring for a patient whose arterial blood gas (ABG) results are: pH
7.28, PaCO2 52 mmHg, and HCO3 25 mEq/L. Which acid-base imbalance is the
patient experiencing?
A. Respiratory Alkalosis
B. Metabolic Acidosis
C. Respiratory Acidosis
D. Metabolic Alkalosis
Answer: C
Rationale: The pH is low (acidosis) and the PaCO2 is high (respiratory cause). The HCO3 is
within normal range, indicating an uncompensated respiratory acidosis.
2. A postoperative patient’s abdominal wound has partially separated, and a
small loop of bowel is protruding. Which is the nurse’s priority action?
A. Apply pressure to the site with a sterile dressing
B. Place the patient in High-Fowler’s position
C. Attempt to gently reinsert the protruding bowel into the abdominal cavity
D. Cover the protruding organ with sterile towels moistened with sterile normal saline
Answer: D
Rationale: Evisceration is a medical emergency. The nurse must protect the organ by
covering it with sterile saline-soaked dressings. Applying pressure or trying to reinsert the
bowel can cause trauma or ischemia.
,3. A nurse is assessing a patient for signs of hypocalcemia. Which of the
following findings would indicate a positive Trousseau’s sign?
A. Twitching of the facial muscles when the facial nerve is tapped
B. Sharp pain in the calf upon dorsiflexion of the foot
C. Carpal spasm induced by inflating a blood pressure cuff above systolic pressure
D. Hyperactive deep tendon reflexes in the lower extremities
Answer: C
Rationale: Trousseau’s sign is carpal spasm caused by ischemia when a BP cuff is inflated.
Facial twitching is Chvostek’s sign. Both are indicators of hypocalcemia.
4. A patient is receiving parenteral nutrition (PN) through a central line. The
nurse notices the bag is empty and a new bag is not yet available from the
pharmacy. Which action should the nurse take?
A. Slow the infusion rate to the lowest setting to keep the vein open
B. Flush the line with heparin and wait for the new bag
C. Hang a bag of 10% dextrose in water (D10W) at the same rate
D. Infuse 0.9% sodium chloride until the PN bag arrives
Answer: C
Rationale: To prevent rebound hypoglycemia when PN is interrupted, the nurse should
infuse a high-concentration dextrose solution like D10W.
5. While assessing an IV site, the nurse notes that the skin is cool to the touch,
pale, and swollen. The patient complains of discomfort. Which complication is
most likely occurring?
A. Infiltration
B. Infection
C. Phlebitis
D. Extravasation of a vesicant
Answer: A
, Rationale: Infiltration is characterized by coolness, pallor, and edema at the site. Phlebitis
would involve warmth and redness.
6. The nurse is teaching a patient how to use an incentive spirometer. Which
instruction is correct?
A. Inhale deeply and rapidly through the mouthpiece
B. Exhale forcefully into the device until the piston rises
C. Inhale slowly and deeply, then hold your breath for 3 to 5 seconds
D. Hold your breath for 10 seconds after exhaling into the device
Answer: C
Rationale: Incentive spirometry requires a slow, deep inhalation to maximize lung
expansion and prevent atelectasis.
7. A patient with a potassium level of 2.8 mEq/L is being monitored. Which of
the following ECG changes should the nurse expect to see?
A. Tall, peaked T waves
B. Presence of U waves and ST segment depression
C. Widened QRS complexes
D. Shortened PR interval
Answer: B
Rationale: Hypokalemia typically causes U waves, flattened or inverted T waves, and ST
depression. Peaked T waves are associated with hyperkalemia.
Update WCU
1. A nurse is caring for a patient whose arterial blood gas (ABG) results are: pH
7.28, PaCO2 52 mmHg, and HCO3 25 mEq/L. Which acid-base imbalance is the
patient experiencing?
A. Respiratory Alkalosis
B. Metabolic Acidosis
C. Respiratory Acidosis
D. Metabolic Alkalosis
Answer: C
Rationale: The pH is low (acidosis) and the PaCO2 is high (respiratory cause). The HCO3 is
within normal range, indicating an uncompensated respiratory acidosis.
2. A postoperative patient’s abdominal wound has partially separated, and a
small loop of bowel is protruding. Which is the nurse’s priority action?
A. Apply pressure to the site with a sterile dressing
B. Place the patient in High-Fowler’s position
C. Attempt to gently reinsert the protruding bowel into the abdominal cavity
D. Cover the protruding organ with sterile towels moistened with sterile normal saline
Answer: D
Rationale: Evisceration is a medical emergency. The nurse must protect the organ by
covering it with sterile saline-soaked dressings. Applying pressure or trying to reinsert the
bowel can cause trauma or ischemia.
,3. A nurse is assessing a patient for signs of hypocalcemia. Which of the
following findings would indicate a positive Trousseau’s sign?
A. Twitching of the facial muscles when the facial nerve is tapped
B. Sharp pain in the calf upon dorsiflexion of the foot
C. Carpal spasm induced by inflating a blood pressure cuff above systolic pressure
D. Hyperactive deep tendon reflexes in the lower extremities
Answer: C
Rationale: Trousseau’s sign is carpal spasm caused by ischemia when a BP cuff is inflated.
Facial twitching is Chvostek’s sign. Both are indicators of hypocalcemia.
4. A patient is receiving parenteral nutrition (PN) through a central line. The
nurse notices the bag is empty and a new bag is not yet available from the
pharmacy. Which action should the nurse take?
A. Slow the infusion rate to the lowest setting to keep the vein open
B. Flush the line with heparin and wait for the new bag
C. Hang a bag of 10% dextrose in water (D10W) at the same rate
D. Infuse 0.9% sodium chloride until the PN bag arrives
Answer: C
Rationale: To prevent rebound hypoglycemia when PN is interrupted, the nurse should
infuse a high-concentration dextrose solution like D10W.
5. While assessing an IV site, the nurse notes that the skin is cool to the touch,
pale, and swollen. The patient complains of discomfort. Which complication is
most likely occurring?
A. Infiltration
B. Infection
C. Phlebitis
D. Extravasation of a vesicant
Answer: A
, Rationale: Infiltration is characterized by coolness, pallor, and edema at the site. Phlebitis
would involve warmth and redness.
6. The nurse is teaching a patient how to use an incentive spirometer. Which
instruction is correct?
A. Inhale deeply and rapidly through the mouthpiece
B. Exhale forcefully into the device until the piston rises
C. Inhale slowly and deeply, then hold your breath for 3 to 5 seconds
D. Hold your breath for 10 seconds after exhaling into the device
Answer: C
Rationale: Incentive spirometry requires a slow, deep inhalation to maximize lung
expansion and prevent atelectasis.
7. A patient with a potassium level of 2.8 mEq/L is being monitored. Which of
the following ECG changes should the nurse expect to see?
A. Tall, peaked T waves
B. Presence of U waves and ST segment depression
C. Widened QRS complexes
D. Shortened PR interval
Answer: B
Rationale: Hypokalemia typically causes U waves, flattened or inverted T waves, and ST
depression. Peaked T waves are associated with hyperkalemia.
