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NU136 EXAM 2 (GALEN) NEWEST 2025 ACTUAL EXAM
TEST BANK| NU 136 FUNDAMENTALS OF NURSING
EXAM 2 REVIEW WITH 350 REAL EXAM QUESTIONS
AND CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) ALREADY GRADED A+ (BRAND NEW!!)
The nurse is preparing to insert a nasogastric tube into a client. The
nurse should place the client in which position for insertion?
a. Right side
b. Low Fowler's
c. High fowler's
d. Supine with the head flat - Correct Answer - C
Rationale: During insertion of a nasogastric tube, the client is placed in
a sitting or high Fowler's position to facilitate insertions of the tube and
reduce the risk of pulmonary aspiration if the client should vomit. The
right side, and low Fowler's and supine positions place the client at risk
for aspiration; in addition, these positions do not facilitate insertion of
the tube.
The nurse inspects the color of the drainage from a nasogastric tube on a
postoperative client approximately 24 hours after gastric surgery. Which
finding indicates the need to notify the health care provider (HCP)?
a. Dark red drainage
b. Dark brown drainage
c. Green-tinged drainage
pg. 1
,2|Page
d. Light yellowish-brown drainage - Correct Answer - A
Rationale: For the first 12 hours after gastric surgery, the nasogastric
tube drainage may be dark brown to dark red. Later, the drainage should
change to a light yellowish-brown color. The presence of bile may cause
a green-tinge. The HCP should be notified if dark red drainage, a sign of
hemorrhage, is noted 24 hours postoperatively.
A nurse is assessing a patient who has had diarrhea for 4 days. Which of
the following findings should the nurse expect? (Select all that apply)
a. Bradycardia
b. Hypotension
c. Elevated temperature
d. Poor skin turgor
e. Peripheral edema - Correct Answer - b, c, d
Rationale: Prolonged diarrhea leads to dehydration, expect the client to
have an elevated temperature, a decrease in blood pressure, poor skin
turgor, tachycardia, and weakened peripheral pulses. Peripheral edema
results from a fluid overload.
A client has a pressure ulcer on the sacrum. While assessing it, the nurse
observes that it has partial thickness, loss of dermis, and a red-pink
wound bed. Which stage will the nurse assign this pressure ulcer?
a. Stage I
b. Stage III
c. Stage II
pg. 2
,3|Page
d. Stage IV - Correct Answer - C
Rationale: Stage I pressure ulcers have intact skin with a reddened area
that may be firm and painful. Stage II pressure ulcers are indicated by
partial thickness, loss of dermis, and a red-pink wound bed. Stage III
pressure ulcers have full-thickness skin loss and may contain slough,
visible subcutaneous tissue, and tunneling. Stage IV pressure ulcers have
full-thickness skin loss and exposed muscle, bone, or tendons.
The tool that predicts the risk of developing a hospital- or facility-
acquired pressure ulcer or injury is called the
a. Braden Scale
b. Likert Scale
c. Misophonia Scale
d. Apgar Scale - Correct Answer - A
Rationale: The Braden Scale uses a score from less than or equal to 9 to
as high as 23. The lower the number, the higher the risk for developing
an acquired ulcer or injury. The Braden Scale should be used on
admission, transfer, and receiving, and with any change in the client's
condition. The Likert Scale is used on questionnaires. The Misophonia
Scale is used for a disorder in which certain sounds trigger emotional or
physiological responses. The Apgar Scale measures the health of a
newborn.
A patient diagnosed with Crohn's disease has a new colostomy. When
assessing the patient's stoma, which of these would alert the HCP that
the stoma has retracted?
pg. 3
, 4|Page
a. Pinkish red and moist
b. Narrowed and flattened
c. Concave and bowl shaped
d. Dry and reddish purple - Correct Answer – C.
Rationale: A colostomy is created when the bowel is pulled through an
opening in the abdominal wall, creating a stoma through which intestinal
contents will pass. A healthy stoma will protrude about 2.5cm with an
open lumen at the top. The stoma should appear pinkish red and moist. A
dry, dusky, or reddish-purple stoma indicates ischemia. A narrowed,
flattened, or constricted stoma indicates stenosis. A concave and bowl-
shaped stoma has retracted. A retracted stoma can be difficult to care for.
Complications include problems maintaining appliance placement,
leading to leakage and sore skin.
An unconscious trauma patient is admitted to the ICU. The HCP
prescribes enteral feedings via the nasogastric (NG) tube. Before the
nurse administers a formula feeding, which finding by the nurse requires
IMMEDIATE action?
a. The volume of residual formula is 90 mL
b. Breath sounds are decreased in the right lower lobe.
c. Urine output for the last 8 hours was 40 mL/hr
d. Bowel sounds are hyperactive in all quadrants - Correct Answer – B.
Rationale: A major risk associated with enteral feedings is aspiration,
resulting in atelectasis and pneumonia. The right lower lobe (RLL) is the
most common site. Clients should be positioned at a minimum of 30
degrees of head elevation during feedings and up to two hours afterward.
pg. 4
NU136 EXAM 2 (GALEN) NEWEST 2025 ACTUAL EXAM
TEST BANK| NU 136 FUNDAMENTALS OF NURSING
EXAM 2 REVIEW WITH 350 REAL EXAM QUESTIONS
AND CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) ALREADY GRADED A+ (BRAND NEW!!)
The nurse is preparing to insert a nasogastric tube into a client. The
nurse should place the client in which position for insertion?
a. Right side
b. Low Fowler's
c. High fowler's
d. Supine with the head flat - Correct Answer - C
Rationale: During insertion of a nasogastric tube, the client is placed in
a sitting or high Fowler's position to facilitate insertions of the tube and
reduce the risk of pulmonary aspiration if the client should vomit. The
right side, and low Fowler's and supine positions place the client at risk
for aspiration; in addition, these positions do not facilitate insertion of
the tube.
The nurse inspects the color of the drainage from a nasogastric tube on a
postoperative client approximately 24 hours after gastric surgery. Which
finding indicates the need to notify the health care provider (HCP)?
a. Dark red drainage
b. Dark brown drainage
c. Green-tinged drainage
pg. 1
,2|Page
d. Light yellowish-brown drainage - Correct Answer - A
Rationale: For the first 12 hours after gastric surgery, the nasogastric
tube drainage may be dark brown to dark red. Later, the drainage should
change to a light yellowish-brown color. The presence of bile may cause
a green-tinge. The HCP should be notified if dark red drainage, a sign of
hemorrhage, is noted 24 hours postoperatively.
A nurse is assessing a patient who has had diarrhea for 4 days. Which of
the following findings should the nurse expect? (Select all that apply)
a. Bradycardia
b. Hypotension
c. Elevated temperature
d. Poor skin turgor
e. Peripheral edema - Correct Answer - b, c, d
Rationale: Prolonged diarrhea leads to dehydration, expect the client to
have an elevated temperature, a decrease in blood pressure, poor skin
turgor, tachycardia, and weakened peripheral pulses. Peripheral edema
results from a fluid overload.
A client has a pressure ulcer on the sacrum. While assessing it, the nurse
observes that it has partial thickness, loss of dermis, and a red-pink
wound bed. Which stage will the nurse assign this pressure ulcer?
a. Stage I
b. Stage III
c. Stage II
pg. 2
,3|Page
d. Stage IV - Correct Answer - C
Rationale: Stage I pressure ulcers have intact skin with a reddened area
that may be firm and painful. Stage II pressure ulcers are indicated by
partial thickness, loss of dermis, and a red-pink wound bed. Stage III
pressure ulcers have full-thickness skin loss and may contain slough,
visible subcutaneous tissue, and tunneling. Stage IV pressure ulcers have
full-thickness skin loss and exposed muscle, bone, or tendons.
The tool that predicts the risk of developing a hospital- or facility-
acquired pressure ulcer or injury is called the
a. Braden Scale
b. Likert Scale
c. Misophonia Scale
d. Apgar Scale - Correct Answer - A
Rationale: The Braden Scale uses a score from less than or equal to 9 to
as high as 23. The lower the number, the higher the risk for developing
an acquired ulcer or injury. The Braden Scale should be used on
admission, transfer, and receiving, and with any change in the client's
condition. The Likert Scale is used on questionnaires. The Misophonia
Scale is used for a disorder in which certain sounds trigger emotional or
physiological responses. The Apgar Scale measures the health of a
newborn.
A patient diagnosed with Crohn's disease has a new colostomy. When
assessing the patient's stoma, which of these would alert the HCP that
the stoma has retracted?
pg. 3
, 4|Page
a. Pinkish red and moist
b. Narrowed and flattened
c. Concave and bowl shaped
d. Dry and reddish purple - Correct Answer – C.
Rationale: A colostomy is created when the bowel is pulled through an
opening in the abdominal wall, creating a stoma through which intestinal
contents will pass. A healthy stoma will protrude about 2.5cm with an
open lumen at the top. The stoma should appear pinkish red and moist. A
dry, dusky, or reddish-purple stoma indicates ischemia. A narrowed,
flattened, or constricted stoma indicates stenosis. A concave and bowl-
shaped stoma has retracted. A retracted stoma can be difficult to care for.
Complications include problems maintaining appliance placement,
leading to leakage and sore skin.
An unconscious trauma patient is admitted to the ICU. The HCP
prescribes enteral feedings via the nasogastric (NG) tube. Before the
nurse administers a formula feeding, which finding by the nurse requires
IMMEDIATE action?
a. The volume of residual formula is 90 mL
b. Breath sounds are decreased in the right lower lobe.
c. Urine output for the last 8 hours was 40 mL/hr
d. Bowel sounds are hyperactive in all quadrants - Correct Answer – B.
Rationale: A major risk associated with enteral feedings is aspiration,
resulting in atelectasis and pneumonia. The right lower lobe (RLL) is the
most common site. Clients should be positioned at a minimum of 30
degrees of head elevation during feedings and up to two hours afterward.
pg. 4
