ADN Final Exam Version 2 | Makeup Comprehensive Exam |
2026/2027 Update Galen College
1. A nurse is assessing a client who has a chest tube connected to a suction
drainage system. Which of the following findings should the nurse report to the
provider?
A. Firmly taped connections between the tube and the drainage system
B. Fluctuation of the water level with respiration
C. Presence of 50 mL of serous drainage in 4 hours
D. Constant bubbling in the water seal chamber
Answer: D
Rationale: Constant bubbling in the water seal chamber indicates an air leak in the system,
which must be addressed. Tidaling (fluctuation) is normal, and 50 mL of drainage over 4
hours is within expected limits.
2. A client is prescribed lisinopril for hypertension. Which of the following
adverse effects should the nurse instruct the client to report immediately?
A. Swelling of the tongue or lips
B. Occasional dry cough
C. Mild dizziness upon standing
D. Increased urination
Answer: A
Rationale: Swelling of the tongue or lips indicates angioedema, a life-threatening adverse
effect of ACE inhibitors. While a dry cough is common, angioedema requires immediate
intervention.
,3. A nurse is caring for a client with a history of alcohol use disorder who is
experiencing tremors and agitation. Which medication should the nurse expect
to administer?
A. Methadone
B. Disulfiram
C. Varenicline
D. Chlordiazepoxide
Answer: D
Rationale: Chlordiazepoxide is a benzodiazepine used to prevent or treat symptoms of
acute alcohol withdrawal, including tremors and agitation.
4. A nurse is reviewing the laboratory results of a client receiving heparin via
continuous IV infusion. The aPTT is 90 seconds (control 30 seconds). Which
action should the nurse take?
A. Stop the infusion and notify the provider
B. Increase the infusion rate
C. Continue the infusion at the current rate
D. Administer vitamin K intramuscularly
Answer: A
Rationale: An aPTT of 90 seconds is significantly above the therapeutic range (usually 1.5
to 2.5 times the control, which would be 45-75 seconds). The infusion should be stopped to
prevent bleeding.
, 5. Which of the following findings is a late sign of increased intracranial pressure
(ICP)?
A. Restlessness and irritability
B. Increased heart rate
C. Dilated and fixed pupils
D. Headache described as ‘worst in my life’
Answer: C
Rationale: Dilated and fixed pupils are a late sign of increased ICP indicating herniation.
Restlessness is an early sign. Cushing’s Triad (bradycardia, widened pulse pressure) is also
a late sign.
6. A nurse is assessing a client with Cushing’s syndrome. Which of the following
findings should the nurse expect?
A. Weight loss and hypotension
B. Bronze skin pigmentation
C. Hyperkalemia and hyponatremia
D. Truncal obesity and moon face
Answer: D
Rationale: Cushing’s syndrome is characterized by excess cortisol, leading to fat
redistribution (truncal obesity, buffalo hump, moon face). Bronze skin is characteristic of
Addison’s disease.
7. A client is admitted with diabetic ketoacidosis (DKA). Which of the following
IV fluids should the nurse prepare to administer first?
A. 0.9% Sodium Chloride
B. 5% Dextrose in 0.45% Sodium Chloride
C. 0.45% Sodium Chloride
D. Lactated Ringer’s
Answer: A
2026/2027 Update Galen College
1. A nurse is assessing a client who has a chest tube connected to a suction
drainage system. Which of the following findings should the nurse report to the
provider?
A. Firmly taped connections between the tube and the drainage system
B. Fluctuation of the water level with respiration
C. Presence of 50 mL of serous drainage in 4 hours
D. Constant bubbling in the water seal chamber
Answer: D
Rationale: Constant bubbling in the water seal chamber indicates an air leak in the system,
which must be addressed. Tidaling (fluctuation) is normal, and 50 mL of drainage over 4
hours is within expected limits.
2. A client is prescribed lisinopril for hypertension. Which of the following
adverse effects should the nurse instruct the client to report immediately?
A. Swelling of the tongue or lips
B. Occasional dry cough
C. Mild dizziness upon standing
D. Increased urination
Answer: A
Rationale: Swelling of the tongue or lips indicates angioedema, a life-threatening adverse
effect of ACE inhibitors. While a dry cough is common, angioedema requires immediate
intervention.
,3. A nurse is caring for a client with a history of alcohol use disorder who is
experiencing tremors and agitation. Which medication should the nurse expect
to administer?
A. Methadone
B. Disulfiram
C. Varenicline
D. Chlordiazepoxide
Answer: D
Rationale: Chlordiazepoxide is a benzodiazepine used to prevent or treat symptoms of
acute alcohol withdrawal, including tremors and agitation.
4. A nurse is reviewing the laboratory results of a client receiving heparin via
continuous IV infusion. The aPTT is 90 seconds (control 30 seconds). Which
action should the nurse take?
A. Stop the infusion and notify the provider
B. Increase the infusion rate
C. Continue the infusion at the current rate
D. Administer vitamin K intramuscularly
Answer: A
Rationale: An aPTT of 90 seconds is significantly above the therapeutic range (usually 1.5
to 2.5 times the control, which would be 45-75 seconds). The infusion should be stopped to
prevent bleeding.
, 5. Which of the following findings is a late sign of increased intracranial pressure
(ICP)?
A. Restlessness and irritability
B. Increased heart rate
C. Dilated and fixed pupils
D. Headache described as ‘worst in my life’
Answer: C
Rationale: Dilated and fixed pupils are a late sign of increased ICP indicating herniation.
Restlessness is an early sign. Cushing’s Triad (bradycardia, widened pulse pressure) is also
a late sign.
6. A nurse is assessing a client with Cushing’s syndrome. Which of the following
findings should the nurse expect?
A. Weight loss and hypotension
B. Bronze skin pigmentation
C. Hyperkalemia and hyponatremia
D. Truncal obesity and moon face
Answer: D
Rationale: Cushing’s syndrome is characterized by excess cortisol, leading to fat
redistribution (truncal obesity, buffalo hump, moon face). Bronze skin is characteristic of
Addison’s disease.
7. A client is admitted with diabetic ketoacidosis (DKA). Which of the following
IV fluids should the nurse prepare to administer first?
A. 0.9% Sodium Chloride
B. 5% Dextrose in 0.45% Sodium Chloride
C. 0.45% Sodium Chloride
D. Lactated Ringer’s
Answer: A
