BSN Advanced Nursing Fundamentals Exam 2 Practice
2026 UPDATED ACTUAL Questions and CORRECT Answers
1. When preparing to administer a medication, the nurse checks the label
against the Medication Administration Record (MAR). How many times should
this check occur?
A. Three times: when removing, when preparing, and before administering.
B. Twice, once at the drawer and once at the bedside.
C. Once, when taking it from the drawer.
D. Four times: including a check with another nurse.
Answer: A
Rationale: Standard safety protocol requires checking the medication three times: when
reaching for the container, when comparing with the MAR after retrieval, and at the
bedside before administration.
2. A patient has a pressure injury that presents as a shallow, open ulcer with a
red-pink wound bed without slough. Which stage is this?
A. Stage 1
B. Stage 3
C. Stage 2
D. Stage 4
Answer: C
Rationale: Stage 2 involves partial-thickness loss of dermis presenting as a shallow open
ulcer with a red-pink wound bed, without slough or bruising.
,3. The nurse is caring for a patient who is 2 days post-operative. The patient
reports sudden chest pain and shortness of breath. Which complication is most
likely?
A. Atelectasis
B. Pulmonary Embolism
C. Pneumonia
D. Hypovolemic Shock
Answer: B
Rationale: Sudden onset of chest pain and dyspnea in a post-operative patient are classic
signs of a pulmonary embolism, a common complication due to immobility.
4. Which site is the preferred location for intramuscular injections in adults due
to the absence of large nerves and blood vessels?
A. Ventrogluteal
B. Dorsogluteal
C. Vastus Lateralis
D. Deltoid
Answer: A
Rationale: The ventrogluteal site is the preferred site for IM injections because it is
situated deep and away from major nerves and blood vessels.
5. While assessing a patient’s IV site, the nurse notes redness, warmth, and a
palpable cord along the vein. These are signs of:
A. Infiltration
B. Extravasation
C. Phlebitis
D. Systemic Infection
Answer: C
, Rationale: Phlebitis is inflammation of a vein; its signs include redness, warmth, pain, and
sometimes a palpable cord.
6. A patient is prescribed a clear liquid diet. Which of the following items can
the nurse provide?
A. Prune juice, yogurt, and water.
B. Orange juice, milk, and coffee.
C. Tomato soup, tea, and ice cream.
D. Apple juice, chicken broth, and gelatin.
Answer: D
Rationale: Clear liquids are those you can see through at room temperature, including
apple juice, broth, and gelatin.
7. What is the most reliable indicator of a patient’s pain level?
A. The patient’s vital signs.
B. The patient’s self-report.
C. The nurse’s clinical judgment.
D. The severity of the injury.
Answer: B
Rationale: Pain is subjective; the most reliable indicator is what the patient says it is.
8. A nurse is inserting an indwelling urinary catheter. What is the priority action
to maintain sterility?
A. Cleaning the meatus with circular motions.
B. Donning sterile gloves before opening the kit.
C. Ensuring the sterile field remains above waist level.
D. Applying lubricant to the catheter tip with a clean hand.
Answer: C
Rationale: Objects below waist level are considered contaminated in a sterile field.
2026 UPDATED ACTUAL Questions and CORRECT Answers
1. When preparing to administer a medication, the nurse checks the label
against the Medication Administration Record (MAR). How many times should
this check occur?
A. Three times: when removing, when preparing, and before administering.
B. Twice, once at the drawer and once at the bedside.
C. Once, when taking it from the drawer.
D. Four times: including a check with another nurse.
Answer: A
Rationale: Standard safety protocol requires checking the medication three times: when
reaching for the container, when comparing with the MAR after retrieval, and at the
bedside before administration.
2. A patient has a pressure injury that presents as a shallow, open ulcer with a
red-pink wound bed without slough. Which stage is this?
A. Stage 1
B. Stage 3
C. Stage 2
D. Stage 4
Answer: C
Rationale: Stage 2 involves partial-thickness loss of dermis presenting as a shallow open
ulcer with a red-pink wound bed, without slough or bruising.
,3. The nurse is caring for a patient who is 2 days post-operative. The patient
reports sudden chest pain and shortness of breath. Which complication is most
likely?
A. Atelectasis
B. Pulmonary Embolism
C. Pneumonia
D. Hypovolemic Shock
Answer: B
Rationale: Sudden onset of chest pain and dyspnea in a post-operative patient are classic
signs of a pulmonary embolism, a common complication due to immobility.
4. Which site is the preferred location for intramuscular injections in adults due
to the absence of large nerves and blood vessels?
A. Ventrogluteal
B. Dorsogluteal
C. Vastus Lateralis
D. Deltoid
Answer: A
Rationale: The ventrogluteal site is the preferred site for IM injections because it is
situated deep and away from major nerves and blood vessels.
5. While assessing a patient’s IV site, the nurse notes redness, warmth, and a
palpable cord along the vein. These are signs of:
A. Infiltration
B. Extravasation
C. Phlebitis
D. Systemic Infection
Answer: C
, Rationale: Phlebitis is inflammation of a vein; its signs include redness, warmth, pain, and
sometimes a palpable cord.
6. A patient is prescribed a clear liquid diet. Which of the following items can
the nurse provide?
A. Prune juice, yogurt, and water.
B. Orange juice, milk, and coffee.
C. Tomato soup, tea, and ice cream.
D. Apple juice, chicken broth, and gelatin.
Answer: D
Rationale: Clear liquids are those you can see through at room temperature, including
apple juice, broth, and gelatin.
7. What is the most reliable indicator of a patient’s pain level?
A. The patient’s vital signs.
B. The patient’s self-report.
C. The nurse’s clinical judgment.
D. The severity of the injury.
Answer: B
Rationale: Pain is subjective; the most reliable indicator is what the patient says it is.
8. A nurse is inserting an indwelling urinary catheter. What is the priority action
to maintain sterility?
A. Cleaning the meatus with circular motions.
B. Donning sterile gloves before opening the kit.
C. Ensuring the sterile field remains above waist level.
D. Applying lubricant to the catheter tip with a clean hand.
Answer: C
Rationale: Objects below waist level are considered contaminated in a sterile field.
