BSN Advanced Nursing Fundamentals Exam 6 Practice
UPDATED ACTUAL Questions and CORRECT Answers
1. A nurse is caring for a client with a chest tube. While checking the drainage
system, the nurse notes continuous bubbling in the water-seal chamber. What is
the nurse’s first action?
A. Document this as a normal finding.
B. Increase the suction pressure.
C. Check the system for an air leak.
D. Clamp the chest tube immediately.
Answer: C
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak in the
system. Intermittent bubbling is normal during expiration or coughing, but continuous
bubbling requires investigation of the tubing and connections.
2. A client’s arterial blood gas (ABG) results are: pH 7.31, PaCO2 50 mmHg, and
HCO3 24 mEq/L. How should the nurse interpret these results?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Respiratory acidosis
D. Metabolic alkalosis
Answer: C
Rationale: A pH below 7.35 indicates acidosis. A PaCO2 above 45 mmHg indicates a
respiratory cause. Since the HCO3 is within the normal range (22-26), it is uncompensated
respiratory acidosis.
,3. Which of the following tasks is most appropriate for a nurse to delegate to an
unlicensed assistive personnel (UAP)?
A. Assessing a patient’s pain level after medication administration.
B. Feeding a stable client who has a high risk for aspiration.
C. Teaching a patient how to use an incentive spirometer.
D. Assisting a stable client with ambulation to the bathroom.
Answer: D
Rationale: UAPs can perform routine tasks for stable patients, such as ADLs and
ambulation. Assessment, teaching, and feeding high-risk patients require the clinical
judgment of an RN.
4. A nurse is preparing to administer 1 unit of packed red blood cells (PRBCs).
Which solution is the only compatible fluid to run with blood products?
A. Lactated Ringer’s
B. 5% Dextrose in Water (D5W)
C. 0.9% Sodium Chloride (Normal Saline)
D. 0.45% Sodium Chloride (Half Normal Saline)
Answer: C
Rationale: Only 0.9% Sodium Chloride is compatible with blood products. Other solutions
can cause hemolysis or clotting of the blood within the IV line.
5. The nurse is monitoring a client receiving Total Parenteral Nutrition (TPN).
Which laboratory value is the priority for the nurse to monitor?
A. Blood glucose
B. Serum sodium
C. Hemoglobin
D. Platelet count
Answer: A
, Rationale: TPN contains high concentrations of glucose, placing the client at high risk for
hyperglycemia. Blood glucose levels are typically monitored every 6 hours.
6. A client is diagnosed with hyperkalemia. Which ECG change should the nurse
expect to see?
A. Prominent U waves
B. Tall, peaked T waves
C. ST-segment depression
D. Prolonged PR interval
Answer: B
Rationale: Hyperkalemia (high potassium) typically manifests as tall, peaked T waves on
an ECG. Prominent U waves are associated with hypokalemia.
7. Which nursing intervention is most effective in preventing ventilator-
associated pneumonia (VAP)?
A. Suctioning the patient every hour.
B. Performing oral care with water once daily.
C. Maintaining the head of the bed at 30 to 45 degrees.
D. Administering prophylactic antibiotics.
Answer: C
Rationale: Elevating the head of the bed to 30-45 degrees reduces the risk of aspiration,
which is a primary cause of VAP. Oral care should be frequent and usually involves
chlorhexidine.
UPDATED ACTUAL Questions and CORRECT Answers
1. A nurse is caring for a client with a chest tube. While checking the drainage
system, the nurse notes continuous bubbling in the water-seal chamber. What is
the nurse’s first action?
A. Document this as a normal finding.
B. Increase the suction pressure.
C. Check the system for an air leak.
D. Clamp the chest tube immediately.
Answer: C
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak in the
system. Intermittent bubbling is normal during expiration or coughing, but continuous
bubbling requires investigation of the tubing and connections.
2. A client’s arterial blood gas (ABG) results are: pH 7.31, PaCO2 50 mmHg, and
HCO3 24 mEq/L. How should the nurse interpret these results?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Respiratory acidosis
D. Metabolic alkalosis
Answer: C
Rationale: A pH below 7.35 indicates acidosis. A PaCO2 above 45 mmHg indicates a
respiratory cause. Since the HCO3 is within the normal range (22-26), it is uncompensated
respiratory acidosis.
,3. Which of the following tasks is most appropriate for a nurse to delegate to an
unlicensed assistive personnel (UAP)?
A. Assessing a patient’s pain level after medication administration.
B. Feeding a stable client who has a high risk for aspiration.
C. Teaching a patient how to use an incentive spirometer.
D. Assisting a stable client with ambulation to the bathroom.
Answer: D
Rationale: UAPs can perform routine tasks for stable patients, such as ADLs and
ambulation. Assessment, teaching, and feeding high-risk patients require the clinical
judgment of an RN.
4. A nurse is preparing to administer 1 unit of packed red blood cells (PRBCs).
Which solution is the only compatible fluid to run with blood products?
A. Lactated Ringer’s
B. 5% Dextrose in Water (D5W)
C. 0.9% Sodium Chloride (Normal Saline)
D. 0.45% Sodium Chloride (Half Normal Saline)
Answer: C
Rationale: Only 0.9% Sodium Chloride is compatible with blood products. Other solutions
can cause hemolysis or clotting of the blood within the IV line.
5. The nurse is monitoring a client receiving Total Parenteral Nutrition (TPN).
Which laboratory value is the priority for the nurse to monitor?
A. Blood glucose
B. Serum sodium
C. Hemoglobin
D. Platelet count
Answer: A
, Rationale: TPN contains high concentrations of glucose, placing the client at high risk for
hyperglycemia. Blood glucose levels are typically monitored every 6 hours.
6. A client is diagnosed with hyperkalemia. Which ECG change should the nurse
expect to see?
A. Prominent U waves
B. Tall, peaked T waves
C. ST-segment depression
D. Prolonged PR interval
Answer: B
Rationale: Hyperkalemia (high potassium) typically manifests as tall, peaked T waves on
an ECG. Prominent U waves are associated with hypokalemia.
7. Which nursing intervention is most effective in preventing ventilator-
associated pneumonia (VAP)?
A. Suctioning the patient every hour.
B. Performing oral care with water once daily.
C. Maintaining the head of the bed at 30 to 45 degrees.
D. Administering prophylactic antibiotics.
Answer: C
Rationale: Elevating the head of the bed to 30-45 degrees reduces the risk of aspiration,
which is a primary cause of VAP. Oral care should be frequent and usually involves
chlorhexidine.
