Page |1
NU 136 EXAM 2 PRACTICE QUESTIONS [QUESTION 1-100]
AND ANSWERS UPDATED 2026/2027 | DETAILED
RATIONALES
Introduction:
This original NU 136 Exam 2 practice set is designed to strengthen clinical judgment,
prioritization, assessment, intervention, communication, and patient-safety skills commonly
emphasized in nursing coursework. The questions use realistic clinical scenarios rather than
recall-only prompts, requiring the learner to recognize significant findings, interpret
assessment data, determine priorities, select appropriate nursing actions, and evaluate
outcomes. The set is intended to complement classroom instruction, assigned readings,
instructor materials, and the official course objectives rather than reproduce an actual
examination. Each question contains one best answer followed by a detailed rationale
explaining the clinical reasoning behind the answer and why the alternatives are less
appropriate. Working through these scenarios can help students identify knowledge gaps,
practice prioritization under pressure, and develop a systematic approach to unfamiliar patient
situations. Students should pay particular attention to airway and breathing concerns,
changes in neurological status, infection indicators, medication safety, mobility risks, fluid
balance, therapeutic communication, and delegation. Repeated practice with these concepts
can improve confidence and help learners prepare more effectively for course examinations
and future clinical practice.
Core Domains Covered:
1. Clinical Judgment and Prioritization — Recognizing cues, analyzing findings, identifying
the most urgent problem, and selecting timely nursing actions.
2. Health Assessment — Performing focused assessments, interpreting abnormal findings,
and identifying changes from baseline.
3. Patient Safety — Preventing falls, medication errors, aspiration, infection transmission,
and other preventable complications.
4. Fluid, Electrolyte, and Physiologic Balance — Recognizing manifestations of common
imbalances and determining appropriate nursing interventions.
5. Infection Prevention and Control — Applying standard precautions, transmission-based
precautions, and appropriate infection-prevention measures.
6. Medication and Treatment Safety — Monitoring therapeutic responses, recognizing adverse
effects, and applying safe medication-administration principles.
,Page |2
7. Communication, Delegation, and Professional Practice — Using therapeutic
communication, appropriate delegation, patient education, and interdisciplinary collaboration.
QUESTIONS
Question 1
A nurse is caring for four hospitalized patients. Which patient should the nurse assess first?
A) A patient with chronic arthritis reporting pain of 6 out of 10
B) A patient with pneumonia who has a respiratory rate of 30/min and new confusion
C) A patient awaiting discharge who has questions about medications
D) A patient with diabetes whose premeal glucose is 178 mg/dL
Rationale: The correct answer is B because tachypnea accompanied by new confusion suggests
impaired oxygenation and possible deterioration. Airway and breathing concerns take priority
over routine pain management, discharge teaching, and a moderately elevated glucose level.
Option A requires intervention but is not the highest priority. Option C involves important
teaching but is not immediately life-threatening. Option D represents hyperglycemia but does not
indicate the same degree of immediate instability.**
Question 2
A patient becomes suddenly restless and anxious after receiving an opioid medication. The
respiratory rate is 8/min. What is the nurse's priority action?
A) Reassure the patient that anxiety can occur after medication
B) Stimulate the patient and immediately assess airway and breathing
C) Document the patient's response and reassess in 30 minutes
D) Offer oral fluids to improve circulation
Rationale: The correct answer is B because a respiratory rate of 8/min following an opioid
suggests opioid-induced respiratory depression. The nurse must immediately assess airway and
breathing and initiate appropriate emergency measures according to facility protocol. Option A
delays treatment. Option C is unsafe because respiratory depression requires immediate
intervention. Option D does not address the underlying problem.**
Question 3
A patient reports dizziness when standing. The nurse notes a blood pressure decrease from
128/76 mmHg while lying down to 96/60 mmHg when standing. Which intervention is most
appropriate?
A) Encourage the patient to stand quickly to improve adaptation
B) Restrict all oral fluids
,Page |3
C) Assist the patient with position changes and implement fall precautions
D) Encourage prolonged standing after each position change
Rationale: The correct answer is C because the findings are consistent with orthostatic
hypotension and increased fall risk. Slow position changes, assistance, and safety precautions
reduce injury risk. Option A increases the risk of falling. Option B could worsen volume
depletion when fluid restriction is not prescribed. Option D increases exposure to the
precipitating condition.**
Question 4
A patient with dysphagia begins coughing repeatedly while eating. What should the nurse do
first?
A) Encourage the patient to continue eating slowly
B) Offer additional water
C) Stop oral intake and assess the patient's airway and respiratory status
D) Document the coughing as an expected finding
Rationale: The correct answer is C because coughing during swallowing can indicate
aspiration. The priority is to stop oral intake and assess airway and breathing. Option A may
increase aspiration. Option B can worsen aspiration depending on swallowing ability. Option D
fails to address a potentially serious complication.**
Question 5
Which finding requires the nurse to intervene most rapidly?
A) Temperature of 37.6°C
B) Heart rate of 88/min
C) Oxygen saturation of 84% with increasing work of breathing
D) Blood pressure of 138/84 mmHg
Rationale: The correct answer is C because significant hypoxemia combined with increased
work of breathing indicates possible respiratory compromise. Oxygenation and breathing take
priority. The other findings are not immediately as concerning in isolation.**
Question 6
A nurse is preparing to administer a medication. The patient's identification band is missing.
What should the nurse do?
A) Ask another patient to confirm the patient's identity
B) Administer the medication because the nurse recognizes the patient
C) Obtain appropriate patient identification before administering the medication
D) Ask the patient's roommate to identify the patient
, Page |4
Rationale: The correct answer is C because patient identification is a fundamental medication-
safety requirement. Recognition or confirmation by another person is insufficient. Options A, B,
and D do not provide a reliable identification process.**
Question 7
A postoperative patient suddenly reports shortness of breath and chest discomfort. The patient
appears anxious and has a heart rate of 122/min. What is the nurse's priority?
A) Encourage ambulation
B) Provide a meal
C) Assess airway and breathing and obtain immediate assistance
D) Wait until the next scheduled vital-sign assessment
Rationale: The correct answer is C because acute dyspnea, chest discomfort, tachycardia, and
anxiety may indicate a serious cardiopulmonary complication. Immediate assessment and
escalation are appropriate. Ambulation could worsen the patient's condition, while waiting
delays potentially lifesaving care.**
Question 8
A patient with an indwelling urinary catheter has cloudy urine and a temperature of 38.4°C.
Which action is most appropriate?
A) Ignore the findings because cloudy urine is always expected
B) Remove the catheter without an order in every circumstance
C) Assess the patient for additional infection findings and notify the appropriate provider
of significant changes
D) Increase the patient's activity level
Rationale: The findings may indicate a urinary infection or another source of infection. The
nurse should perform an appropriate assessment, review trends, and communicate significant
findings. Option A dismisses potentially important cues. Catheter removal may be appropriate in
some circumstances but should follow the clinical plan and applicable orders/protocols. Activity
does not address the suspected infection.**
Question 9
A patient says, “I am scared about what is going to happen.” Which response demonstrates
therapeutic communication?
A) “There is nothing to worry about.”
B) “You should try not to think about it.”
C) “Tell me more about what concerns you most.”
D) “Everyone feels that way in the hospital.”
NU 136 EXAM 2 PRACTICE QUESTIONS [QUESTION 1-100]
AND ANSWERS UPDATED 2026/2027 | DETAILED
RATIONALES
Introduction:
This original NU 136 Exam 2 practice set is designed to strengthen clinical judgment,
prioritization, assessment, intervention, communication, and patient-safety skills commonly
emphasized in nursing coursework. The questions use realistic clinical scenarios rather than
recall-only prompts, requiring the learner to recognize significant findings, interpret
assessment data, determine priorities, select appropriate nursing actions, and evaluate
outcomes. The set is intended to complement classroom instruction, assigned readings,
instructor materials, and the official course objectives rather than reproduce an actual
examination. Each question contains one best answer followed by a detailed rationale
explaining the clinical reasoning behind the answer and why the alternatives are less
appropriate. Working through these scenarios can help students identify knowledge gaps,
practice prioritization under pressure, and develop a systematic approach to unfamiliar patient
situations. Students should pay particular attention to airway and breathing concerns,
changes in neurological status, infection indicators, medication safety, mobility risks, fluid
balance, therapeutic communication, and delegation. Repeated practice with these concepts
can improve confidence and help learners prepare more effectively for course examinations
and future clinical practice.
Core Domains Covered:
1. Clinical Judgment and Prioritization — Recognizing cues, analyzing findings, identifying
the most urgent problem, and selecting timely nursing actions.
2. Health Assessment — Performing focused assessments, interpreting abnormal findings,
and identifying changes from baseline.
3. Patient Safety — Preventing falls, medication errors, aspiration, infection transmission,
and other preventable complications.
4. Fluid, Electrolyte, and Physiologic Balance — Recognizing manifestations of common
imbalances and determining appropriate nursing interventions.
5. Infection Prevention and Control — Applying standard precautions, transmission-based
precautions, and appropriate infection-prevention measures.
6. Medication and Treatment Safety — Monitoring therapeutic responses, recognizing adverse
effects, and applying safe medication-administration principles.
,Page |2
7. Communication, Delegation, and Professional Practice — Using therapeutic
communication, appropriate delegation, patient education, and interdisciplinary collaboration.
QUESTIONS
Question 1
A nurse is caring for four hospitalized patients. Which patient should the nurse assess first?
A) A patient with chronic arthritis reporting pain of 6 out of 10
B) A patient with pneumonia who has a respiratory rate of 30/min and new confusion
C) A patient awaiting discharge who has questions about medications
D) A patient with diabetes whose premeal glucose is 178 mg/dL
Rationale: The correct answer is B because tachypnea accompanied by new confusion suggests
impaired oxygenation and possible deterioration. Airway and breathing concerns take priority
over routine pain management, discharge teaching, and a moderately elevated glucose level.
Option A requires intervention but is not the highest priority. Option C involves important
teaching but is not immediately life-threatening. Option D represents hyperglycemia but does not
indicate the same degree of immediate instability.**
Question 2
A patient becomes suddenly restless and anxious after receiving an opioid medication. The
respiratory rate is 8/min. What is the nurse's priority action?
A) Reassure the patient that anxiety can occur after medication
B) Stimulate the patient and immediately assess airway and breathing
C) Document the patient's response and reassess in 30 minutes
D) Offer oral fluids to improve circulation
Rationale: The correct answer is B because a respiratory rate of 8/min following an opioid
suggests opioid-induced respiratory depression. The nurse must immediately assess airway and
breathing and initiate appropriate emergency measures according to facility protocol. Option A
delays treatment. Option C is unsafe because respiratory depression requires immediate
intervention. Option D does not address the underlying problem.**
Question 3
A patient reports dizziness when standing. The nurse notes a blood pressure decrease from
128/76 mmHg while lying down to 96/60 mmHg when standing. Which intervention is most
appropriate?
A) Encourage the patient to stand quickly to improve adaptation
B) Restrict all oral fluids
,Page |3
C) Assist the patient with position changes and implement fall precautions
D) Encourage prolonged standing after each position change
Rationale: The correct answer is C because the findings are consistent with orthostatic
hypotension and increased fall risk. Slow position changes, assistance, and safety precautions
reduce injury risk. Option A increases the risk of falling. Option B could worsen volume
depletion when fluid restriction is not prescribed. Option D increases exposure to the
precipitating condition.**
Question 4
A patient with dysphagia begins coughing repeatedly while eating. What should the nurse do
first?
A) Encourage the patient to continue eating slowly
B) Offer additional water
C) Stop oral intake and assess the patient's airway and respiratory status
D) Document the coughing as an expected finding
Rationale: The correct answer is C because coughing during swallowing can indicate
aspiration. The priority is to stop oral intake and assess airway and breathing. Option A may
increase aspiration. Option B can worsen aspiration depending on swallowing ability. Option D
fails to address a potentially serious complication.**
Question 5
Which finding requires the nurse to intervene most rapidly?
A) Temperature of 37.6°C
B) Heart rate of 88/min
C) Oxygen saturation of 84% with increasing work of breathing
D) Blood pressure of 138/84 mmHg
Rationale: The correct answer is C because significant hypoxemia combined with increased
work of breathing indicates possible respiratory compromise. Oxygenation and breathing take
priority. The other findings are not immediately as concerning in isolation.**
Question 6
A nurse is preparing to administer a medication. The patient's identification band is missing.
What should the nurse do?
A) Ask another patient to confirm the patient's identity
B) Administer the medication because the nurse recognizes the patient
C) Obtain appropriate patient identification before administering the medication
D) Ask the patient's roommate to identify the patient
, Page |4
Rationale: The correct answer is C because patient identification is a fundamental medication-
safety requirement. Recognition or confirmation by another person is insufficient. Options A, B,
and D do not provide a reliable identification process.**
Question 7
A postoperative patient suddenly reports shortness of breath and chest discomfort. The patient
appears anxious and has a heart rate of 122/min. What is the nurse's priority?
A) Encourage ambulation
B) Provide a meal
C) Assess airway and breathing and obtain immediate assistance
D) Wait until the next scheduled vital-sign assessment
Rationale: The correct answer is C because acute dyspnea, chest discomfort, tachycardia, and
anxiety may indicate a serious cardiopulmonary complication. Immediate assessment and
escalation are appropriate. Ambulation could worsen the patient's condition, while waiting
delays potentially lifesaving care.**
Question 8
A patient with an indwelling urinary catheter has cloudy urine and a temperature of 38.4°C.
Which action is most appropriate?
A) Ignore the findings because cloudy urine is always expected
B) Remove the catheter without an order in every circumstance
C) Assess the patient for additional infection findings and notify the appropriate provider
of significant changes
D) Increase the patient's activity level
Rationale: The findings may indicate a urinary infection or another source of infection. The
nurse should perform an appropriate assessment, review trends, and communicate significant
findings. Option A dismisses potentially important cues. Catheter removal may be appropriate in
some circumstances but should follow the clinical plan and applicable orders/protocols. Activity
does not address the suspected infection.**
Question 9
A patient says, “I am scared about what is going to happen.” Which response demonstrates
therapeutic communication?
A) “There is nothing to worry about.”
B) “You should try not to think about it.”
C) “Tell me more about what concerns you most.”
D) “Everyone feels that way in the hospital.”
