NURS 103: Fundamentals of Nursing - Comprehensive Final Exam 2026
|WCU
1. A nurse is reviewing a patient’s arterial blood gas (ABG) results: pH 7.30,
PaCO2 52 mmHg, and HCO3 26 mEq/L. Which acid-base imbalance does this
represent?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis
Answer: C
Rationale: The pH is low (<7.35), indicating acidosis. The PaCO2 is high (>45 mmHg),
indicating a respiratory cause. The HCO3 is within normal range, suggesting no
compensation yet.
2. Which nursing action is the priority when a patient experiences an
anaphylactic reaction to an intravenous antibiotic?
A. Administering intramuscular epinephrine
B. Notifying the healthcare provider
C. Stopping the infusion immediately
D. Elevating the patient’s legs
Answer: C
Rationale: The first step in any transfusion or infusion reaction is to stop the offending
agent to prevent further exposure before interventions begin.
,3. A nurse is preparing to administer a subcutaneous injection of heparin. Which
action should the nurse take?
A. Apply firm pressure to the site for 1-2 minutes after injection
B. Massage the site after injection to increase absorption
C. Aspirate for blood return before injecting
D. Inject the medication into the deltoid muscle
Answer: A
Rationale: Heparin can cause bruising; applying pressure helps prevent hematoma
formation. Massaging and aspiration are contraindicated for heparin.
4. Which ethical principle is the nurse upholding when they support a patient’s
decision to refuse chemotherapy despite the family’s wishes?
A. Beneficence
B. Autonomy
C. Justice
D. Nonmaleficence
Answer: B
Rationale: Autonomy refers to the right of the patient to make their own healthcare
decisions without coercion.
5. A nurse observes a thin, foul-smelling, greenish-yellow discharge from a
surgical wound. How should the nurse document this finding?
A. Serosanguineous drainage
B. Purulent drainage
C. Serous drainage
D. Sanguineous drainage
Answer: B
Rationale: Purulent drainage is thick, often malodorous, and contains pus, indicating
infection. It can be yellow, green, or brown.
, 6. When performing a physical assessment on an older adult, which finding is
considered a normal age-related change?
A. Increased skin elasticity
B. Improved night vision
C. Decreased peripheral pulse intensity
D. Increased bladder capacity
Answer: C
Rationale: Aging often leads to arterial stiffening and decreased cardiac output, which can
result in slightly diminished peripheral pulses.
7. A patient with a high risk for falls is being admitted. Which intervention
should the nurse implement first?
A. Apply physical restraints
B. Place the bed in the lowest position
C. Provide a bedside commode
D. Administer a mild sedative
Answer: B
Rationale: Safety first: placing the bed in the lowest position is a primary non-restrictive
intervention to minimize injury risk.
8. The nurse is teaching a patient how to use an incentive spirometer. What
instruction should be included?
A. Exhale forcefully into the device
B. Use the device only once every 8 hours
C. Hold your breath for 30 seconds after inhalation
D. Inhale slowly and deeply through the mouthpiece
Answer: D
Rationale: Incentive spirometry encourages deep breathing through slow, sustained
inhalation to prevent atelectasis.
|WCU
1. A nurse is reviewing a patient’s arterial blood gas (ABG) results: pH 7.30,
PaCO2 52 mmHg, and HCO3 26 mEq/L. Which acid-base imbalance does this
represent?
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis
Answer: C
Rationale: The pH is low (<7.35), indicating acidosis. The PaCO2 is high (>45 mmHg),
indicating a respiratory cause. The HCO3 is within normal range, suggesting no
compensation yet.
2. Which nursing action is the priority when a patient experiences an
anaphylactic reaction to an intravenous antibiotic?
A. Administering intramuscular epinephrine
B. Notifying the healthcare provider
C. Stopping the infusion immediately
D. Elevating the patient’s legs
Answer: C
Rationale: The first step in any transfusion or infusion reaction is to stop the offending
agent to prevent further exposure before interventions begin.
,3. A nurse is preparing to administer a subcutaneous injection of heparin. Which
action should the nurse take?
A. Apply firm pressure to the site for 1-2 minutes after injection
B. Massage the site after injection to increase absorption
C. Aspirate for blood return before injecting
D. Inject the medication into the deltoid muscle
Answer: A
Rationale: Heparin can cause bruising; applying pressure helps prevent hematoma
formation. Massaging and aspiration are contraindicated for heparin.
4. Which ethical principle is the nurse upholding when they support a patient’s
decision to refuse chemotherapy despite the family’s wishes?
A. Beneficence
B. Autonomy
C. Justice
D. Nonmaleficence
Answer: B
Rationale: Autonomy refers to the right of the patient to make their own healthcare
decisions without coercion.
5. A nurse observes a thin, foul-smelling, greenish-yellow discharge from a
surgical wound. How should the nurse document this finding?
A. Serosanguineous drainage
B. Purulent drainage
C. Serous drainage
D. Sanguineous drainage
Answer: B
Rationale: Purulent drainage is thick, often malodorous, and contains pus, indicating
infection. It can be yellow, green, or brown.
, 6. When performing a physical assessment on an older adult, which finding is
considered a normal age-related change?
A. Increased skin elasticity
B. Improved night vision
C. Decreased peripheral pulse intensity
D. Increased bladder capacity
Answer: C
Rationale: Aging often leads to arterial stiffening and decreased cardiac output, which can
result in slightly diminished peripheral pulses.
7. A patient with a high risk for falls is being admitted. Which intervention
should the nurse implement first?
A. Apply physical restraints
B. Place the bed in the lowest position
C. Provide a bedside commode
D. Administer a mild sedative
Answer: B
Rationale: Safety first: placing the bed in the lowest position is a primary non-restrictive
intervention to minimize injury risk.
8. The nurse is teaching a patient how to use an incentive spirometer. What
instruction should be included?
A. Exhale forcefully into the device
B. Use the device only once every 8 hours
C. Hold your breath for 30 seconds after inhalation
D. Inhale slowly and deeply through the mouthpiece
Answer: D
Rationale: Incentive spirometry encourages deep breathing through slow, sustained
inhalation to prevent atelectasis.
