NU 136 Exam 4 | Fundamentals of Nursing
Comprehensive Nursing Practice Exam (2026/2027) - Galen College
(1) A nurse is caring for a client with a history of COPD who is receiving oxygen at 2 L/min
via nasal cannula. The client's SpO2 is 90%. Which action should the nurse take?
A. Increase the oxygen flow to 6 L/min immediately.
B. Continue to monitor as 88-92% is an expected range for COPD.
C. Switch the client to a non-rebreather mask.
D. Encourage the client to breathe faster.
CORRECT ANSWER: B
Rationale: In clients with COPD, high oxygen concentrations can suppress the hypoxic drive to
breathe. A target SpO2 of 88-92% is often appropriate and safe for these clients.
(2) When performing oropharyngeal suctioning, which action should the nurse take to
prevent hypoxia?
A. Suction for 30 seconds at a time.
B. Apply suction while inserting the catheter.
C. Limit suctioning to 10-15 seconds per pass.
D. Perform suctioning every 15 minutes routinely.
CORRECT ANSWER: C
Rationale: Suctioning should be limited to 10-15 seconds to prevent hypoxia and mucosal trauma.
Suction is only applied during withdrawal, never during insertion.
(3) A nurse is assessing a client's stoma 2 days after a colostomy. Which finding requires
immediate notification of the surgeon?
A. The stoma is bright red and moist.
B. The stoma is dark purple or black.
C. There is slight edema around the stoma.
D. Small amounts of blood are present when cleaning the stoma.
CORRECT ANSWER: B
Rationale: A stoma that is dark purple, black, or pale indicates compromised blood flow (ischemia
or necrosis) and is a surgical emergency. A healthy stoma should be red/pink and moist.
,(4) Which intervention should the nurse implement to prevent catheter-associated
urinary tract infections (CAUTI)?
A. Clean the peri-urethral area with povidone-iodine daily.
B. Keep the drainage bag below the level of the bladder.
C. Change the catheter every 72 hours.
D. Disconnect the catheter from the bag once a shift to empty it.
CORRECT ANSWER: B
Rationale: Keeping the drainage bag below the bladder prevents the backflow of contaminated
urine into the bladder, which is a primary cause of CAUTI.
(5) A nurse is caring for a client with a Stage 3 pressure injury. How should the nurse
describe this wound in the documentation?
A. Non-blanchable erythema of intact skin.
B. Partial-thickness loss of dermis presenting as a shallow open ulcer.
C. Full-thickness tissue loss with visible subcutaneous fat.
D. Full-thickness tissue loss with exposed bone, tendon, or muscle.
CORRECT ANSWER: C
Rationale: Stage 3 involves full-thickness tissue loss where subcutaneous fat may be visible, but
bone, tendon, or muscle are not exposed (which would be Stage 4).
(6) During the assessment of a surgical wound, the nurse notes the presence of thick,
yellow drainage. How should this be documented?
A. Serous
B. Sanguineous
C. Serosanguineous
D. Purulent
CORRECT ANSWER: D
Rationale: Purulent drainage is thick and can be yellow, green, or brown, often indicating
infection. Serous is clear; sanguineous is bloody; serosanguineous is pink/watery.
,(7) A client is experiencing severe diarrhea. Which acid-base imbalance is the client most
at risk for developing?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
CORRECT ANSWER: C
Rationale: Diarrhea involves the loss of bicarbonate from the lower GI tract. Loss of base leads to
Metabolic Acidosis ('base out the butt').
(8) A nurse is caring for a client with macular degeneration. What should the nurse
expect the client to report?
A. Loss of peripheral vision.
B. Loss of central vision.
C. Floating spots in the visual field.
D. Sudden excruciating eye pain.
CORRECT ANSWER: B
Rationale: Macular degeneration affects the macula of the eye, causing a loss of central vision,
while peripheral vision usually remains intact.
(9) To prevent 'foot drop' in a client with long-term immobility, which device should the
nurse use?
A. Trochanter rolls
B. Abductor pillow
C. Foot boots or high-top sneakers
D. Trapeze bar
CORRECT ANSWER: C
Rationale: Foot boots or high-top sneakers maintain the feet in dorsiflexion, preventing the
permanent plantar flexion known as foot drop.
, (10) Which nursing intervention is a priority for a client with a history of seizures?
A. Keep a padded tongue blade at the bedside.
B. Ensure suction equipment and oxygen are available at the bedside.
C. Restrain all four extremities.
D. Place the client in a prone position.
CORRECT ANSWER: B
Rationale: Seizure precautions include having suction and oxygen ready to maintain the airway.
Padded tongue blades are contraindicated as they can cause injury or airway obstruction.
(11) A nurse is caring for a client with a history of COPD who is receiving oxygen at 2 L/
min via nasal cannula. The client's SpO2 is 90%. Which action should the nurse take?
A. Increase the oxygen flow to 6 L/min immediately.
B. Continue to monitor as 88-92% is an expected range for COPD.
C. Switch the client to a non-rebreather mask.
D. Encourage the client to breathe faster.
CORRECT ANSWER: B
Rationale: In clients with COPD, high oxygen concentrations can suppress the hypoxic drive to
breathe. A target SpO2 of 88-92% is often appropriate and safe for these clients.
(12) When performing oropharyngeal suctioning, which action should the nurse take to
prevent hypoxia?
A. Suction for 30 seconds at a time.
B. Apply suction while inserting the catheter.
C. Limit suctioning to 10-15 seconds per pass.
D. Perform suctioning every 15 minutes routinely.
CORRECT ANSWER: C
Rationale: Suctioning should be limited to 10-15 seconds to prevent hypoxia and mucosal trauma.
Suction is only applied during withdrawal, never during insertion.
Comprehensive Nursing Practice Exam (2026/2027) - Galen College
(1) A nurse is caring for a client with a history of COPD who is receiving oxygen at 2 L/min
via nasal cannula. The client's SpO2 is 90%. Which action should the nurse take?
A. Increase the oxygen flow to 6 L/min immediately.
B. Continue to monitor as 88-92% is an expected range for COPD.
C. Switch the client to a non-rebreather mask.
D. Encourage the client to breathe faster.
CORRECT ANSWER: B
Rationale: In clients with COPD, high oxygen concentrations can suppress the hypoxic drive to
breathe. A target SpO2 of 88-92% is often appropriate and safe for these clients.
(2) When performing oropharyngeal suctioning, which action should the nurse take to
prevent hypoxia?
A. Suction for 30 seconds at a time.
B. Apply suction while inserting the catheter.
C. Limit suctioning to 10-15 seconds per pass.
D. Perform suctioning every 15 minutes routinely.
CORRECT ANSWER: C
Rationale: Suctioning should be limited to 10-15 seconds to prevent hypoxia and mucosal trauma.
Suction is only applied during withdrawal, never during insertion.
(3) A nurse is assessing a client's stoma 2 days after a colostomy. Which finding requires
immediate notification of the surgeon?
A. The stoma is bright red and moist.
B. The stoma is dark purple or black.
C. There is slight edema around the stoma.
D. Small amounts of blood are present when cleaning the stoma.
CORRECT ANSWER: B
Rationale: A stoma that is dark purple, black, or pale indicates compromised blood flow (ischemia
or necrosis) and is a surgical emergency. A healthy stoma should be red/pink and moist.
,(4) Which intervention should the nurse implement to prevent catheter-associated
urinary tract infections (CAUTI)?
A. Clean the peri-urethral area with povidone-iodine daily.
B. Keep the drainage bag below the level of the bladder.
C. Change the catheter every 72 hours.
D. Disconnect the catheter from the bag once a shift to empty it.
CORRECT ANSWER: B
Rationale: Keeping the drainage bag below the bladder prevents the backflow of contaminated
urine into the bladder, which is a primary cause of CAUTI.
(5) A nurse is caring for a client with a Stage 3 pressure injury. How should the nurse
describe this wound in the documentation?
A. Non-blanchable erythema of intact skin.
B. Partial-thickness loss of dermis presenting as a shallow open ulcer.
C. Full-thickness tissue loss with visible subcutaneous fat.
D. Full-thickness tissue loss with exposed bone, tendon, or muscle.
CORRECT ANSWER: C
Rationale: Stage 3 involves full-thickness tissue loss where subcutaneous fat may be visible, but
bone, tendon, or muscle are not exposed (which would be Stage 4).
(6) During the assessment of a surgical wound, the nurse notes the presence of thick,
yellow drainage. How should this be documented?
A. Serous
B. Sanguineous
C. Serosanguineous
D. Purulent
CORRECT ANSWER: D
Rationale: Purulent drainage is thick and can be yellow, green, or brown, often indicating
infection. Serous is clear; sanguineous is bloody; serosanguineous is pink/watery.
,(7) A client is experiencing severe diarrhea. Which acid-base imbalance is the client most
at risk for developing?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
CORRECT ANSWER: C
Rationale: Diarrhea involves the loss of bicarbonate from the lower GI tract. Loss of base leads to
Metabolic Acidosis ('base out the butt').
(8) A nurse is caring for a client with macular degeneration. What should the nurse
expect the client to report?
A. Loss of peripheral vision.
B. Loss of central vision.
C. Floating spots in the visual field.
D. Sudden excruciating eye pain.
CORRECT ANSWER: B
Rationale: Macular degeneration affects the macula of the eye, causing a loss of central vision,
while peripheral vision usually remains intact.
(9) To prevent 'foot drop' in a client with long-term immobility, which device should the
nurse use?
A. Trochanter rolls
B. Abductor pillow
C. Foot boots or high-top sneakers
D. Trapeze bar
CORRECT ANSWER: C
Rationale: Foot boots or high-top sneakers maintain the feet in dorsiflexion, preventing the
permanent plantar flexion known as foot drop.
, (10) Which nursing intervention is a priority for a client with a history of seizures?
A. Keep a padded tongue blade at the bedside.
B. Ensure suction equipment and oxygen are available at the bedside.
C. Restrain all four extremities.
D. Place the client in a prone position.
CORRECT ANSWER: B
Rationale: Seizure precautions include having suction and oxygen ready to maintain the airway.
Padded tongue blades are contraindicated as they can cause injury or airway obstruction.
(11) A nurse is caring for a client with a history of COPD who is receiving oxygen at 2 L/
min via nasal cannula. The client's SpO2 is 90%. Which action should the nurse take?
A. Increase the oxygen flow to 6 L/min immediately.
B. Continue to monitor as 88-92% is an expected range for COPD.
C. Switch the client to a non-rebreather mask.
D. Encourage the client to breathe faster.
CORRECT ANSWER: B
Rationale: In clients with COPD, high oxygen concentrations can suppress the hypoxic drive to
breathe. A target SpO2 of 88-92% is often appropriate and safe for these clients.
(12) When performing oropharyngeal suctioning, which action should the nurse take to
prevent hypoxia?
A. Suction for 30 seconds at a time.
B. Apply suction while inserting the catheter.
C. Limit suctioning to 10-15 seconds per pass.
D. Perform suctioning every 15 minutes routinely.
CORRECT ANSWER: C
Rationale: Suctioning should be limited to 10-15 seconds to prevent hypoxia and mucosal trauma.
Suction is only applied during withdrawal, never during insertion.
