NURS 103 Fundamentals of Nursing - Actual Exam 3 (WCU Curriculum)
2026 |WCU
1. A nurse is assessing a patient’s arterial blood gas (ABG) results which show a
pH of 7.30, PaCO2 of 52 mmHg, and HCO3 of 26 mEq/L. Which acid-base
imbalance is the patient experiencing?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Metabolic Alkalosis
D. Respiratory Acidosis
Answer: D
Rationale: A pH below 7.35 indicates acidosis. A PaCO2 above 45 mmHg indicates a
respiratory cause, while the HCO3 is within normal range (22-26 mEq/L), confirming
uncompensated respiratory acidosis.
2. When performing a physical assessment, in which order should the nurse
assess the abdomen?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Inspection, Auscultation, Palpation
Answer: A
Rationale: For the abdomen, the correct order is Inspection, Auscultation, Percussion, and
then Palpation. This is to avoid altering bowel sounds through manipulation before
listening.
,3. A nurse is caring for a patient with a Clostridium difficile infection. Which
hand hygiene method is mandatory?
A. Washing with soap and water
B. Alcohol-based hand rub for 15 seconds
C. Using a chlorhexidine-impregnated wipe
D. Rinsing with warm water only
Answer: A
Rationale: C. difficile spores are resistant to alcohol-based rubs. Mechanical friction and
rinsing with soap and water are necessary to physically remove the spores from the hands.
4. The nurse is preparing to administer an intramuscular (IM) injection to an
average-sized adult. Which needle gauge and length are most appropriate for
the ventrogluteal site?
A. 22 gauge, 1.5 inch
B. 18 gauge, 1.5 inch
C. 25 gauge, 5/8 inch
D. 27 gauge, 1/2 inch
Answer: A
Rationale: For an IM injection in the ventrogluteal site of an adult, a 20-23 gauge needle
(typically 22) and a 1.5-inch length are standard to reach the muscle layer.
5. Which ethical principle is violated if a nurse tells a patient they will return in
15 minutes with pain medication but does not return for an hour?
A. Autonomy
B. Fidelity
C. Beneficence
D. Justice
Answer: B
, Rationale: Fidelity refers to the obligation to be faithful to commitments and promises
made to others. Failing to return as promised violates this principle.
6. A patient’s blood pressure is 150/96 mmHg. Which classification does this fall
under according to current AHA/ACC guidelines?
A. Elevated
B. Hypertension Stage 1
C. Hypertensive Crisis
D. Hypertension Stage 2
Answer: D
Rationale: Stage 2 Hypertension is defined as a systolic pressure of at least 140 mmHg or a
diastolic pressure of at least 90 mmHg.
7. The nurse is preparing to suction a patient with a tracheostomy. Which action
is the priority to prevent hypoxia during the procedure?
A. Apply suction while inserting the catheter
B. Limit suctioning to 20 seconds per pass
C. Hyperoxygenate the patient with 100% oxygen before the procedure
D. Use a sterile technique during the procedure
Answer: C
Rationale: Hyperoxygenation before suctioning is critical to provide a reserve of oxygen,
as the suctioning process removes both secretions and oxygen from the airway.
8. A nurse observes a fire in a patient’s wastebasket. Using the RACE acronym,
which action should the nurse take first?
A. Extinguish the fire using a fire extinguisher
B. Activate the fire alarm system
C. Confine the fire by closing the door
D. Rescue and remove the patient from the room
Answer: D
2026 |WCU
1. A nurse is assessing a patient’s arterial blood gas (ABG) results which show a
pH of 7.30, PaCO2 of 52 mmHg, and HCO3 of 26 mEq/L. Which acid-base
imbalance is the patient experiencing?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Metabolic Alkalosis
D. Respiratory Acidosis
Answer: D
Rationale: A pH below 7.35 indicates acidosis. A PaCO2 above 45 mmHg indicates a
respiratory cause, while the HCO3 is within normal range (22-26 mEq/L), confirming
uncompensated respiratory acidosis.
2. When performing a physical assessment, in which order should the nurse
assess the abdomen?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Inspection, Auscultation, Palpation
Answer: A
Rationale: For the abdomen, the correct order is Inspection, Auscultation, Percussion, and
then Palpation. This is to avoid altering bowel sounds through manipulation before
listening.
,3. A nurse is caring for a patient with a Clostridium difficile infection. Which
hand hygiene method is mandatory?
A. Washing with soap and water
B. Alcohol-based hand rub for 15 seconds
C. Using a chlorhexidine-impregnated wipe
D. Rinsing with warm water only
Answer: A
Rationale: C. difficile spores are resistant to alcohol-based rubs. Mechanical friction and
rinsing with soap and water are necessary to physically remove the spores from the hands.
4. The nurse is preparing to administer an intramuscular (IM) injection to an
average-sized adult. Which needle gauge and length are most appropriate for
the ventrogluteal site?
A. 22 gauge, 1.5 inch
B. 18 gauge, 1.5 inch
C. 25 gauge, 5/8 inch
D. 27 gauge, 1/2 inch
Answer: A
Rationale: For an IM injection in the ventrogluteal site of an adult, a 20-23 gauge needle
(typically 22) and a 1.5-inch length are standard to reach the muscle layer.
5. Which ethical principle is violated if a nurse tells a patient they will return in
15 minutes with pain medication but does not return for an hour?
A. Autonomy
B. Fidelity
C. Beneficence
D. Justice
Answer: B
, Rationale: Fidelity refers to the obligation to be faithful to commitments and promises
made to others. Failing to return as promised violates this principle.
6. A patient’s blood pressure is 150/96 mmHg. Which classification does this fall
under according to current AHA/ACC guidelines?
A. Elevated
B. Hypertension Stage 1
C. Hypertensive Crisis
D. Hypertension Stage 2
Answer: D
Rationale: Stage 2 Hypertension is defined as a systolic pressure of at least 140 mmHg or a
diastolic pressure of at least 90 mmHg.
7. The nurse is preparing to suction a patient with a tracheostomy. Which action
is the priority to prevent hypoxia during the procedure?
A. Apply suction while inserting the catheter
B. Limit suctioning to 20 seconds per pass
C. Hyperoxygenate the patient with 100% oxygen before the procedure
D. Use a sterile technique during the procedure
Answer: C
Rationale: Hyperoxygenation before suctioning is critical to provide a reserve of oxygen,
as the suctioning process removes both secretions and oxygen from the airway.
8. A nurse observes a fire in a patient’s wastebasket. Using the RACE acronym,
which action should the nurse take first?
A. Extinguish the fire using a fire extinguisher
B. Activate the fire alarm system
C. Confine the fire by closing the door
D. Rescue and remove the patient from the room
Answer: D
