Advanced Nursing Fundamentals Final Exam Version 2 Practice
Questions 2026 |Rationales
1. A nurse is assessing a client’s surgical wound and notes the presence of red,
moist tissue that is composed of new blood vessels. How should the nurse
document this finding?
A. Slough
B. Purulent exudate
C. Eschar
D. Granulation tissue
Answer: D
Rationale: Granulation tissue is red, moist tissue composed of new blood vessels, which
indicates progression toward healing.
2. Which nursing action is most effective in preventing the transmission of
Vancomycin-Resistant Enterococcus (VRE) in a hospital setting?
A. Wearing a mask when within 3 feet of the patient
B. Implementing contact precautions, including gloves and gown
C. Performing hand hygiene with alcohol-based rub after patient contact
D. Instructing the patient to wear a mask during transport
Answer: B
Rationale: VRE is transmitted via direct or indirect contact; therefore, contact precautions
(gown and gloves) are the standard for preventing transmission.
,3. A client is experiencing dyspnea and the nurse notes a respiratory rate of 28
breaths/min. Which position should the nurse place the client in to optimize
chest expansion?
A. High-Fowler’s
B. Prone
C. Trendelenburg
D. Supine
Answer: A
Rationale: High-Fowler’s position allows for maximum diaphragmatic excursion and chest
expansion, helping to alleviate dyspnea.
4. When evaluating a patient’s arterial blood gas (ABG) results, the nurse notes
a pH of 7.30, a PaCO2 of 52 mmHg, and an HCO3 of 24 mEq/L. Which acid-base
imbalance is present?
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 with a normal
HCO3 indicates that the respiratory system is the cause of the acidosis.
5. A nurse is preparing to administer an intramuscular injection into the
ventrogluteal site. Which landmark should the nurse use to locate the site?
A. The acromion process
B. The greater trochanter and the anterior superior iliac spine
C. The vastus lateralis muscle
D. The iliac crest and the posterior superior iliac spine
Answer: B
, Rationale: The ventrogluteal site is located by placing the palm over the greater trochanter
and the index finger on the anterior superior iliac spine.
6. A patient has been on bed rest for three days. What is the priority nursing
intervention to prevent deep vein thrombosis (DVT)?
A. Massaging the lower extremities twice daily
B. Encouraging active range-of-motion exercises and ankle pumps
C. Restricting fluid intake to decrease blood volume
D. Keeping the knees in a flexed position with a pillow
Answer: B
Rationale: Ankle pumps and range-of-motion exercises promote venous return and
prevent stasis, reducing the risk of DVT.
7. The nurse is caring for a patient with a Stage 3 pressure injury. Which
characteristic should the nurse expect to observe?
A. Non-blanchable erythema of intact skin
B. Partial-thickness skin loss involving the dermis
C. Full-thickness skin loss involving damage to subcutaneous tissue
D. Full-thickness skin loss with exposed bone or muscle
Answer: C
Rationale: Stage 3 pressure injuries involve full-thickness skin loss where subcutaneous
fat may be visible, but bone, tendon, or muscle are not exposed.
8. Which ethical principle is the nurse practicing when they honor a client’s
refusal of a life-sustaining treatment?
A. Beneficence
B. Autonomy
C. Justice
D. Fidelity
Answer: B
Questions 2026 |Rationales
1. A nurse is assessing a client’s surgical wound and notes the presence of red,
moist tissue that is composed of new blood vessels. How should the nurse
document this finding?
A. Slough
B. Purulent exudate
C. Eschar
D. Granulation tissue
Answer: D
Rationale: Granulation tissue is red, moist tissue composed of new blood vessels, which
indicates progression toward healing.
2. Which nursing action is most effective in preventing the transmission of
Vancomycin-Resistant Enterococcus (VRE) in a hospital setting?
A. Wearing a mask when within 3 feet of the patient
B. Implementing contact precautions, including gloves and gown
C. Performing hand hygiene with alcohol-based rub after patient contact
D. Instructing the patient to wear a mask during transport
Answer: B
Rationale: VRE is transmitted via direct or indirect contact; therefore, contact precautions
(gown and gloves) are the standard for preventing transmission.
,3. A client is experiencing dyspnea and the nurse notes a respiratory rate of 28
breaths/min. Which position should the nurse place the client in to optimize
chest expansion?
A. High-Fowler’s
B. Prone
C. Trendelenburg
D. Supine
Answer: A
Rationale: High-Fowler’s position allows for maximum diaphragmatic excursion and chest
expansion, helping to alleviate dyspnea.
4. When evaluating a patient’s arterial blood gas (ABG) results, the nurse notes
a pH of 7.30, a PaCO2 of 52 mmHg, and an HCO3 of 24 mEq/L. Which acid-base
imbalance is present?
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 with a normal
HCO3 indicates that the respiratory system is the cause of the acidosis.
5. A nurse is preparing to administer an intramuscular injection into the
ventrogluteal site. Which landmark should the nurse use to locate the site?
A. The acromion process
B. The greater trochanter and the anterior superior iliac spine
C. The vastus lateralis muscle
D. The iliac crest and the posterior superior iliac spine
Answer: B
, Rationale: The ventrogluteal site is located by placing the palm over the greater trochanter
and the index finger on the anterior superior iliac spine.
6. A patient has been on bed rest for three days. What is the priority nursing
intervention to prevent deep vein thrombosis (DVT)?
A. Massaging the lower extremities twice daily
B. Encouraging active range-of-motion exercises and ankle pumps
C. Restricting fluid intake to decrease blood volume
D. Keeping the knees in a flexed position with a pillow
Answer: B
Rationale: Ankle pumps and range-of-motion exercises promote venous return and
prevent stasis, reducing the risk of DVT.
7. The nurse is caring for a patient with a Stage 3 pressure injury. Which
characteristic should the nurse expect to observe?
A. Non-blanchable erythema of intact skin
B. Partial-thickness skin loss involving the dermis
C. Full-thickness skin loss involving damage to subcutaneous tissue
D. Full-thickness skin loss with exposed bone or muscle
Answer: C
Rationale: Stage 3 pressure injuries involve full-thickness skin loss where subcutaneous
fat may be visible, but bone, tendon, or muscle are not exposed.
8. Which ethical principle is the nurse practicing when they honor a client’s
refusal of a life-sustaining treatment?
A. Beneficence
B. Autonomy
C. Justice
D. Fidelity
Answer: B
