BSN Semester 4 Comprehensive Nursing Final Exam 2026/2027
UPDATE
1. A nurse is caring for a client with a chest tube. The nurse notes continuous
bubbling in the water seal chamber. Which action should the nurse take first?
A. Check the system for an air leak
B. Document this as a normal finding
C. Increase the suction level
D. Clamp the chest tube immediately
Answer: A
Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the
system. The nurse must locate the leak starting from the client site down to the drainage
unit.
2. A client is admitted with Diabetic Ketoacidosis (DKA). Which IV fluid should
the nurse anticipate the provider ordering initially?
A. 5% Dextrose in Water (D5W)
B. 0.45% Sodium Chloride
C. 0.9% Sodium Chloride
D. 3% Sodium Chloride
Answer: C
Rationale: Initial management of DKA involves rapid volume expansion with isotonic
saline (0.9% NaCl) to restore perfusion.
,3. Which task is most appropriate for the RN to delegate to an Unlicensed
Assistive Personnel (UAP)?
A. Feeding a client who has a high risk for aspiration
B. Measuring and recording intake and output
C. Evaluating a client’s response to pain medication
D. Performing an initial post-operative assessment
Answer: B
Rationale: Measuring and recording I&O is a technical skill within the scope of practice for
a UAP. Evaluation and assessment are tasks that cannot be delegated.
4. A client is receiving Magnesium Sulfate for preeclampsia. Which finding
should the nurse report to the provider immediately?
A. Respiratory rate of 14 breaths/min
B. Urine output of 20 mL/hour
C. Presence of deep tendon reflexes (2+)
D. Blood pressure of 150/90 mmHg
Answer: B
Rationale: Urine output less than 30 mL/hr can lead to magnesium toxicity, as magnesium
is excreted by the kidneys. Decreased urine output is a critical sign.
5. A nurse is assessing a client with a history of heart failure who is taking
Digoxin. Which symptom is an early sign of Digoxin toxicity?
A. Tachycardia
B. Hypertension
C. Anorexia and nausea
D. Increased appetite
Answer: C
Rationale: Gastrointestinal symptoms like anorexia, nausea, and vomiting are usually the
earliest signs of Digoxin toxicity.
, 6. A client presents with a potassium level of 6.2 mEq/L. Which EKG change is
most characteristic of this condition?
A. ST-segment depression
B. Shortened PR interval
C. Prominent U waves
D. Tall, peaked T waves
Answer: D
Rationale: Hyperkalemia (K+ > 5.0) causes characteristic tall, peaked T waves on an EKG.
Prominent U waves are associated with hypokalemia.
7. In the Emergency Department, which client should the nurse triage as the
highest priority?
A. A client complaining of sudden epigastric pain and diaphoresis
B. A client with a simple fracture of the radius
C. A client with a temperature of 101.5 F and a sore throat
D. A client with a superficial laceration to the forearm
Answer: A
Rationale: Sudden epigastric pain accompanied by diaphoresis can indicate a myocardial
infarction, which is a life-threatening emergency (Emergent/Red tag).
8. A child is admitted with suspected Intussusception. Which clinical
manifestation is most likely to be present?
A. Ribbon-like stools
B. Projectile vomiting
C. Steatorrhea
D. Currant jelly-like stools
Answer: D
Rationale: Currant jelly stools (blood and mucus mixed) are a classic hallmark of
intussusception. Projectile vomiting is seen in pyloric stenosis.
UPDATE
1. A nurse is caring for a client with a chest tube. The nurse notes continuous
bubbling in the water seal chamber. Which action should the nurse take first?
A. Check the system for an air leak
B. Document this as a normal finding
C. Increase the suction level
D. Clamp the chest tube immediately
Answer: A
Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the
system. The nurse must locate the leak starting from the client site down to the drainage
unit.
2. A client is admitted with Diabetic Ketoacidosis (DKA). Which IV fluid should
the nurse anticipate the provider ordering initially?
A. 5% Dextrose in Water (D5W)
B. 0.45% Sodium Chloride
C. 0.9% Sodium Chloride
D. 3% Sodium Chloride
Answer: C
Rationale: Initial management of DKA involves rapid volume expansion with isotonic
saline (0.9% NaCl) to restore perfusion.
,3. Which task is most appropriate for the RN to delegate to an Unlicensed
Assistive Personnel (UAP)?
A. Feeding a client who has a high risk for aspiration
B. Measuring and recording intake and output
C. Evaluating a client’s response to pain medication
D. Performing an initial post-operative assessment
Answer: B
Rationale: Measuring and recording I&O is a technical skill within the scope of practice for
a UAP. Evaluation and assessment are tasks that cannot be delegated.
4. A client is receiving Magnesium Sulfate for preeclampsia. Which finding
should the nurse report to the provider immediately?
A. Respiratory rate of 14 breaths/min
B. Urine output of 20 mL/hour
C. Presence of deep tendon reflexes (2+)
D. Blood pressure of 150/90 mmHg
Answer: B
Rationale: Urine output less than 30 mL/hr can lead to magnesium toxicity, as magnesium
is excreted by the kidneys. Decreased urine output is a critical sign.
5. A nurse is assessing a client with a history of heart failure who is taking
Digoxin. Which symptom is an early sign of Digoxin toxicity?
A. Tachycardia
B. Hypertension
C. Anorexia and nausea
D. Increased appetite
Answer: C
Rationale: Gastrointestinal symptoms like anorexia, nausea, and vomiting are usually the
earliest signs of Digoxin toxicity.
, 6. A client presents with a potassium level of 6.2 mEq/L. Which EKG change is
most characteristic of this condition?
A. ST-segment depression
B. Shortened PR interval
C. Prominent U waves
D. Tall, peaked T waves
Answer: D
Rationale: Hyperkalemia (K+ > 5.0) causes characteristic tall, peaked T waves on an EKG.
Prominent U waves are associated with hypokalemia.
7. In the Emergency Department, which client should the nurse triage as the
highest priority?
A. A client complaining of sudden epigastric pain and diaphoresis
B. A client with a simple fracture of the radius
C. A client with a temperature of 101.5 F and a sore throat
D. A client with a superficial laceration to the forearm
Answer: A
Rationale: Sudden epigastric pain accompanied by diaphoresis can indicate a myocardial
infarction, which is a life-threatening emergency (Emergent/Red tag).
8. A child is admitted with suspected Intussusception. Which clinical
manifestation is most likely to be present?
A. Ribbon-like stools
B. Projectile vomiting
C. Steatorrhea
D. Currant jelly-like stools
Answer: D
Rationale: Currant jelly stools (blood and mucus mixed) are a classic hallmark of
intussusception. Projectile vomiting is seen in pyloric stenosis.
