NU 136 Exam 2 – Fundamentals of Nursing (2026/2027) 50+
Actual Questions & Correct Answers with Rationales | Galen
College of Nursing
1. What is the primary reason for using warm solution when administering an enema?
a. cold solution can cause cramping
b. it increases peristalsis
c. it reduces the risk of fluid overload
d. it soothes the intestinal muscles
Correct Answer: a. cold solution can cause cramping
Rationale: Warm enema solution is used because cold solution can cause cramping and discomfort.
Warm solution is closer to body temperature, which helps prevent intestinal spasms and promotes
patient comfort during the procedure. While warm solution may also help increase peristalsis, the
primary reason is to prevent cramping caused by cold solution.
2. A nurse identifies an immobile patient as high risk for constipation. Which intervention is most
effective?
a. administering sleep medication
b. keeping the patient in bed
c. limiting fluid intake
d. encouraging a high-fiber diet
Correct Answer: d. encouraging a high-fiber diet
Rationale: A high-fiber diet is the most effective intervention for preventing constipation in immobile
patients. Fiber adds bulk to stool, which promotes peristalsis and facilitates bowel elimination.
Limiting fluid intake would worsen constipation, and keeping the patient in bed would decrease
mobility further. Sleep medication does not address constipation prevention.
3. Which position is MOST appropriate for a patient to assume when receiving an enema?
a. prone
b. supine
c. fowler's position
d. left sims (side lying)
Correct Answer: d. left sims (side lying)
Rationale: The left Sims' position (left side-lying) is the preferred position for enema administration.
This position allows the solution to flow by gravity into the descending colon and sigmoid colon,
following the natural anatomical curve of the colon. It also helps the patient retain the solution for
the required amount of time.
,4. A patient with chronic constipation should be educated on the potential risks of frequent use of
stimulant laxatives, such as:
a. sudden diarrhea
b. hyperkalemia
c. dependency for bowel movements
d. increased appetite
Correct Answer: c. dependency for bowel movements
Rationale: Frequent use of stimulant laxatives can lead to laxative dependency, where the bowel
becomes reliant on laxatives to produce a bowel movement. This occurs because stimulant laxatives
irritate the bowel lining, and over time the colon loses its natural ability to contract and propel stool.
Other risks include electrolyte imbalances and dehydration, but dependency is a major concern.
5. What is the primary purpose of using a wound VAC in wound management?
a. to provide antibiotic treatment
b. to suture wounds
c. to debride necrotic tissue
d. to remove exudate and reduce edema
Correct Answer: d. to remove exudate and reduce edema
Rationale: A wound VAC (Vacuum-Assisted Closure) uses negative pressure to remove excess
exudate, reduce edema, and promote granulation tissue formation. It does not provide antibiotics,
suture wounds, or debride necrotic tissue (though it may help prepare the wound bed for healing).
The negative pressure also increases blood flow to the wound area.
6. A patient who is non-weight bearing on the left leg needs to learn to use crutches. The nurse
instructs the patient to:
a. place all weight on the right foot
b. bear weight equally on both feet
c. alternate weight between feet when moving
d. use the left foot for balance only
Correct Answer: a. place all weight on the right foot
Rationale: When a patient is non-weight bearing on the left leg, all weight must be placed on the
unaffected (right) leg. The patient should use a three-point gait pattern, where both crutches and the
unaffected leg bear weight while the affected leg is held off the floor. This prevents further injury to
the non-weight-bearing limb.
7. A nurse is preparing to apply an elastic bandage to a patient's sprained ankle. Which action is
most appropriate?
, a. leaving the toes exposed for observations
b. using even pressure when wrapping the bandage
c. starting the wrap at the upper calf and moving downward
d. wrapping the bandage loosely to allow for swelling
Correct Answer: b. using even pressure when wrapping the bandage
Rationale: When applying an elastic bandage, even pressure is essential to promote venous return
and prevent constriction. Bandages should be applied from distal to proximal (not upper calf
downward), and the toes should be left exposed for circulation checks. Wrapping too loosely would
not provide therapeutic support, while wrapping too tightly could impair circulation.
8. Which phase of wound healing involves the formation of collagen and granulation tissue to fill
the wound?
a. maturation phase
b. proliferative phase
c. inflammatory phase
Correct Answer: b. proliferative phase
Rationale: The proliferative phase (also called the fibroblastic phase) is the second stage of wound
healing, occurring approximately 3-24 days after injury. During this phase, fibroblasts synthesize
collagen, granulation tissue forms to fill the wound, and new blood vessels develop (angiogenesis).
The inflammatory phase is the initial response, and the maturation phase involves remodeling of
collagen.
9. A patient's wound is red, warm, swollen, and increasingly painful. The nurse suspects:
a. ischemia
b. normal inflammatory response
c. infection
d. hematoma formation
Correct Answer: c. infection
Rationale: Redness (erythema), warmth, swelling (edema), and increasing pain are classic signs of
wound infection. While some redness and warmth may be present in a normal inflammatory
response, the combination of all these signs—especially increasing pain—suggests infection.
Ischemia would present with pale, cool skin, and hematoma would present with a localized collection
of blood.
10. A patient with a history of recurrent urinary tract infections (UTIs) should be advised to:
a. limit fluid intake to decrease urinary frequency
b. hold urine for extended periods to strengthen bladder muscles
c. use perineal wipes from back to front after toileting
d. drink cranberry juice or take cranberry supplements
Actual Questions & Correct Answers with Rationales | Galen
College of Nursing
1. What is the primary reason for using warm solution when administering an enema?
a. cold solution can cause cramping
b. it increases peristalsis
c. it reduces the risk of fluid overload
d. it soothes the intestinal muscles
Correct Answer: a. cold solution can cause cramping
Rationale: Warm enema solution is used because cold solution can cause cramping and discomfort.
Warm solution is closer to body temperature, which helps prevent intestinal spasms and promotes
patient comfort during the procedure. While warm solution may also help increase peristalsis, the
primary reason is to prevent cramping caused by cold solution.
2. A nurse identifies an immobile patient as high risk for constipation. Which intervention is most
effective?
a. administering sleep medication
b. keeping the patient in bed
c. limiting fluid intake
d. encouraging a high-fiber diet
Correct Answer: d. encouraging a high-fiber diet
Rationale: A high-fiber diet is the most effective intervention for preventing constipation in immobile
patients. Fiber adds bulk to stool, which promotes peristalsis and facilitates bowel elimination.
Limiting fluid intake would worsen constipation, and keeping the patient in bed would decrease
mobility further. Sleep medication does not address constipation prevention.
3. Which position is MOST appropriate for a patient to assume when receiving an enema?
a. prone
b. supine
c. fowler's position
d. left sims (side lying)
Correct Answer: d. left sims (side lying)
Rationale: The left Sims' position (left side-lying) is the preferred position for enema administration.
This position allows the solution to flow by gravity into the descending colon and sigmoid colon,
following the natural anatomical curve of the colon. It also helps the patient retain the solution for
the required amount of time.
,4. A patient with chronic constipation should be educated on the potential risks of frequent use of
stimulant laxatives, such as:
a. sudden diarrhea
b. hyperkalemia
c. dependency for bowel movements
d. increased appetite
Correct Answer: c. dependency for bowel movements
Rationale: Frequent use of stimulant laxatives can lead to laxative dependency, where the bowel
becomes reliant on laxatives to produce a bowel movement. This occurs because stimulant laxatives
irritate the bowel lining, and over time the colon loses its natural ability to contract and propel stool.
Other risks include electrolyte imbalances and dehydration, but dependency is a major concern.
5. What is the primary purpose of using a wound VAC in wound management?
a. to provide antibiotic treatment
b. to suture wounds
c. to debride necrotic tissue
d. to remove exudate and reduce edema
Correct Answer: d. to remove exudate and reduce edema
Rationale: A wound VAC (Vacuum-Assisted Closure) uses negative pressure to remove excess
exudate, reduce edema, and promote granulation tissue formation. It does not provide antibiotics,
suture wounds, or debride necrotic tissue (though it may help prepare the wound bed for healing).
The negative pressure also increases blood flow to the wound area.
6. A patient who is non-weight bearing on the left leg needs to learn to use crutches. The nurse
instructs the patient to:
a. place all weight on the right foot
b. bear weight equally on both feet
c. alternate weight between feet when moving
d. use the left foot for balance only
Correct Answer: a. place all weight on the right foot
Rationale: When a patient is non-weight bearing on the left leg, all weight must be placed on the
unaffected (right) leg. The patient should use a three-point gait pattern, where both crutches and the
unaffected leg bear weight while the affected leg is held off the floor. This prevents further injury to
the non-weight-bearing limb.
7. A nurse is preparing to apply an elastic bandage to a patient's sprained ankle. Which action is
most appropriate?
, a. leaving the toes exposed for observations
b. using even pressure when wrapping the bandage
c. starting the wrap at the upper calf and moving downward
d. wrapping the bandage loosely to allow for swelling
Correct Answer: b. using even pressure when wrapping the bandage
Rationale: When applying an elastic bandage, even pressure is essential to promote venous return
and prevent constriction. Bandages should be applied from distal to proximal (not upper calf
downward), and the toes should be left exposed for circulation checks. Wrapping too loosely would
not provide therapeutic support, while wrapping too tightly could impair circulation.
8. Which phase of wound healing involves the formation of collagen and granulation tissue to fill
the wound?
a. maturation phase
b. proliferative phase
c. inflammatory phase
Correct Answer: b. proliferative phase
Rationale: The proliferative phase (also called the fibroblastic phase) is the second stage of wound
healing, occurring approximately 3-24 days after injury. During this phase, fibroblasts synthesize
collagen, granulation tissue forms to fill the wound, and new blood vessels develop (angiogenesis).
The inflammatory phase is the initial response, and the maturation phase involves remodeling of
collagen.
9. A patient's wound is red, warm, swollen, and increasingly painful. The nurse suspects:
a. ischemia
b. normal inflammatory response
c. infection
d. hematoma formation
Correct Answer: c. infection
Rationale: Redness (erythema), warmth, swelling (edema), and increasing pain are classic signs of
wound infection. While some redness and warmth may be present in a normal inflammatory
response, the combination of all these signs—especially increasing pain—suggests infection.
Ischemia would present with pale, cool skin, and hematoma would present with a localized collection
of blood.
10. A patient with a history of recurrent urinary tract infections (UTIs) should be advised to:
a. limit fluid intake to decrease urinary frequency
b. hold urine for extended periods to strengthen bladder muscles
c. use perineal wipes from back to front after toileting
d. drink cranberry juice or take cranberry supplements
