,Hondros College NUR 160 Nursing
Fundamentals Exam 2 Practice Questions
2026–2027 | Fundamentals, Patient Safety &
Rationales
Q1. A nurse is caring for a client who is restless, confused, and has an oxygen saturation of
88% on room air. Which action should the nurse take first?
A. Reassure the client that everything is fine.
B. Apply oxygen via nasal cannula and notify the provider.
C. Document the finding and continue to monitor.
D. Restrain the client to prevent falls.
Correct Answer: B. Apply oxygen via nasal cannula and notify the provider.
Rationale: Restlessness, confusion, and an SpO2 of 88% indicate hypoxemia with early signs of
hypoxia (agitation, confusion, restlessness, anxiety, and tachycardia). The nurse must
intervene immediately to improve oxygenation. Applying oxygen and notifying the provider
are the priority actions. Reassurance, documentation without intervention, and restraints are
unsafe or inappropriate.
Key Takeaway: Early hypoxia signs include restlessness, anxiety, and tachycardia; act
immediately.
Q2. A nurse is preparing to administer intravenous potassium chloride to a client. Which
action is most critical to prevent a serious adverse event?
A. Administer the medication via IV push over 2 minutes.
B. Use an IV infusion pump and verify the rate with a second nurse.
C. Administer the medication undiluted via peripheral IV.
D. Document the administration before starting the infusion.
Correct Answer: B. Use an IV infusion pump and verify the rate with a second nurse.
,Rationale: IV potassium is a high-alert medication that can cause fatal cardiac dysrhythmias if
infused too rapidly. Using an infusion pump and an independent double-check are standard
safety practices to control the rate and verify the concentration. IV push, undiluted
administration, and documenting before administration are unsafe.
Key Takeaway: IV potassium requires a pump and an independent double-check.
Q3. A client is prescribed sublingual nitroglycerin for chest pain. Which instruction should the
nurse provide to ensure the medication works effectively?
A. "Swallow the tablet whole with a full glass of water."
B. "Place the tablet under your tongue and let it dissolve completely."
C. "Chew the tablet thoroughly before swallowing it."
D. "Crush the tablet and mix it with applesauce."
Correct Answer: B. "Place the tablet under your tongue and let it dissolve completely."
Rationale: Sublingual medications are absorbed directly into the bloodstream through the
highly vascular mucous membranes under the tongue, bypassing the gastrointestinal tract
and first-pass metabolism. Swallowing, chewing, or crushing the tablet alters absorption and
delays therapeutic effect.
Key Takeaway: Sublingual medications dissolve under the tongue for rapid absorption.
Q4. A client who had abdominal surgery 2 days ago reports feeling something give way in the
incision. The nurse notes a large amount of serosanguineous drainage and loops of intestine
protruding from the wound. Which action should the nurse take first?
A. Attempt to push the intestines back into the wound.
B. Cover the protruding organs with sterile gauze moistened with normal saline.
C. Apply a tight abdominal binder.
D. Leave the wound open to air and notify the provider.
Correct Answer: B. Cover the protruding organs with sterile gauze moistened with normal
saline.
, Rationale: This client has wound evisceration, a surgical emergency. The priority is to cover
the protruding organs with sterile gauze moistened with normal saline to prevent drying and
infection. Pushing the intestines back, applying a tight binder, or leaving the wound open are
unsafe and can cause further harm. The nurse should position the client supine with knees
bent and notify the provider immediately.
Key Takeaway: For evisceration, cover with sterile saline-moistened gauze and notify the
provider.
Q5. A nurse is caring for a client receiving a blood transfusion who develops fever, chills, and
flank pain. Which action should the nurse take first?
A. Slow the transfusion rate.
B. Stop the transfusion immediately.
C. Administer acetaminophen as prescribed.
D. Obtain a urine sample for hemoglobinuria.
Correct Answer: B. Stop the transfusion immediately.
Rationale: Fever, chills, and flank pain suggest an acute hemolytic transfusion reaction, which
can be life-threatening. The first action is to stop the transfusion immediately, maintain IV
access with normal saline, and notify the provider. Slowing the transfusion would allow more
incompatible blood to infuse. Acetaminophen does not address the underlying reaction. A
urine sample is obtained after stopping the transfusion to assess for hemoglobinuria.
Key Takeaway: Stop the transfusion first for any suspected reaction; then support and notify.
Q6. A nurse is teaching a client with COPD about home oxygen therapy. Which flow rate is
appropriate for this client?
A. 1 to 2 L/min via nasal cannula.
B. 4 to 6 L/min via simple face mask.
C. 8 to 10 L/min via nonrebreather mask.
D. 12 to 15 L/min via Venturi mask.
Correct Answer: A. 1 to 2 L/min via nasal cannula.
Fundamentals Exam 2 Practice Questions
2026–2027 | Fundamentals, Patient Safety &
Rationales
Q1. A nurse is caring for a client who is restless, confused, and has an oxygen saturation of
88% on room air. Which action should the nurse take first?
A. Reassure the client that everything is fine.
B. Apply oxygen via nasal cannula and notify the provider.
C. Document the finding and continue to monitor.
D. Restrain the client to prevent falls.
Correct Answer: B. Apply oxygen via nasal cannula and notify the provider.
Rationale: Restlessness, confusion, and an SpO2 of 88% indicate hypoxemia with early signs of
hypoxia (agitation, confusion, restlessness, anxiety, and tachycardia). The nurse must
intervene immediately to improve oxygenation. Applying oxygen and notifying the provider
are the priority actions. Reassurance, documentation without intervention, and restraints are
unsafe or inappropriate.
Key Takeaway: Early hypoxia signs include restlessness, anxiety, and tachycardia; act
immediately.
Q2. A nurse is preparing to administer intravenous potassium chloride to a client. Which
action is most critical to prevent a serious adverse event?
A. Administer the medication via IV push over 2 minutes.
B. Use an IV infusion pump and verify the rate with a second nurse.
C. Administer the medication undiluted via peripheral IV.
D. Document the administration before starting the infusion.
Correct Answer: B. Use an IV infusion pump and verify the rate with a second nurse.
,Rationale: IV potassium is a high-alert medication that can cause fatal cardiac dysrhythmias if
infused too rapidly. Using an infusion pump and an independent double-check are standard
safety practices to control the rate and verify the concentration. IV push, undiluted
administration, and documenting before administration are unsafe.
Key Takeaway: IV potassium requires a pump and an independent double-check.
Q3. A client is prescribed sublingual nitroglycerin for chest pain. Which instruction should the
nurse provide to ensure the medication works effectively?
A. "Swallow the tablet whole with a full glass of water."
B. "Place the tablet under your tongue and let it dissolve completely."
C. "Chew the tablet thoroughly before swallowing it."
D. "Crush the tablet and mix it with applesauce."
Correct Answer: B. "Place the tablet under your tongue and let it dissolve completely."
Rationale: Sublingual medications are absorbed directly into the bloodstream through the
highly vascular mucous membranes under the tongue, bypassing the gastrointestinal tract
and first-pass metabolism. Swallowing, chewing, or crushing the tablet alters absorption and
delays therapeutic effect.
Key Takeaway: Sublingual medications dissolve under the tongue for rapid absorption.
Q4. A client who had abdominal surgery 2 days ago reports feeling something give way in the
incision. The nurse notes a large amount of serosanguineous drainage and loops of intestine
protruding from the wound. Which action should the nurse take first?
A. Attempt to push the intestines back into the wound.
B. Cover the protruding organs with sterile gauze moistened with normal saline.
C. Apply a tight abdominal binder.
D. Leave the wound open to air and notify the provider.
Correct Answer: B. Cover the protruding organs with sterile gauze moistened with normal
saline.
, Rationale: This client has wound evisceration, a surgical emergency. The priority is to cover
the protruding organs with sterile gauze moistened with normal saline to prevent drying and
infection. Pushing the intestines back, applying a tight binder, or leaving the wound open are
unsafe and can cause further harm. The nurse should position the client supine with knees
bent and notify the provider immediately.
Key Takeaway: For evisceration, cover with sterile saline-moistened gauze and notify the
provider.
Q5. A nurse is caring for a client receiving a blood transfusion who develops fever, chills, and
flank pain. Which action should the nurse take first?
A. Slow the transfusion rate.
B. Stop the transfusion immediately.
C. Administer acetaminophen as prescribed.
D. Obtain a urine sample for hemoglobinuria.
Correct Answer: B. Stop the transfusion immediately.
Rationale: Fever, chills, and flank pain suggest an acute hemolytic transfusion reaction, which
can be life-threatening. The first action is to stop the transfusion immediately, maintain IV
access with normal saline, and notify the provider. Slowing the transfusion would allow more
incompatible blood to infuse. Acetaminophen does not address the underlying reaction. A
urine sample is obtained after stopping the transfusion to assess for hemoglobinuria.
Key Takeaway: Stop the transfusion first for any suspected reaction; then support and notify.
Q6. A nurse is teaching a client with COPD about home oxygen therapy. Which flow rate is
appropriate for this client?
A. 1 to 2 L/min via nasal cannula.
B. 4 to 6 L/min via simple face mask.
C. 8 to 10 L/min via nonrebreather mask.
D. 12 to 15 L/min via Venturi mask.
Correct Answer: A. 1 to 2 L/min via nasal cannula.
