Page |1
NU 136 EXAM 2 QUESTIONS WITH RATIONALES ACTUAL
EXAM [ QUESTION 1- 200] AND ANSWERS UPDATED 2026/2027|
100% VERIFIED|DETAILED RATIONALES –PASS GUARANTEED
A+ GRADED |INSTANT DOWNLOAD
Introduction:
NU 136 Exam 2 is designed as an original, comprehensive practice resource to help nursing
students strengthen their clinical reasoning, assessment, prioritization, communication, safety,
and evidence-based nursing knowledge. This practice set uses scenario-based questions that
require students to apply concepts rather than simply recall definitions. The questions are
structured to resemble the level of reasoning commonly expected in nursing examinations,
while remaining original study material rather than reproduced examination questions or a
brain dump. The set emphasizes recognizing relevant assessment findings, identifying
priorities, selecting appropriate nursing interventions, evaluating outcomes, and
distinguishing expected findings from those requiring immediate action. Detailed rationales
are provided after every question so learners can understand not only which option is best, but
also why the alternatives are less appropriate. Students can use the questions for independent
revision, classroom preparation, or timed practice. Repeated review of the rationales can help
identify knowledge gaps, improve clinical judgment, and build confidence before an
examination.
Core Domains Covered:
1. Health Assessment and Clinical Data Interpretation — Applies systematic assessment
techniques, recognizes significant findings, and distinguishes expected from abnormal data.
2. Nursing Process and Clinical Judgment — Focuses on assessment, nursing diagnoses,
planning, implementation, evaluation, and prioritization of patient needs.
3. Safety and Infection Prevention — Covers standard precautions, transmission-based
precautions, environmental safety, fall prevention, and prevention of healthcare-associated
infections.
4. Fundamentals of Patient Care — Addresses hygiene, mobility, positioning, nutrition,
elimination, comfort, skin integrity, and basic nursing interventions.
5. Communication and Therapeutic Relationships — Emphasizes therapeutic communication,
patient education, professional boundaries, cultural considerations, and effective
documentation.
6. Medication and Treatment Safety — Covers medication administration principles, adverse
effects, patient identification, monitoring, and prevention of medication errors.
,Page |2
7. Ethical, Legal, and Professional Nursing Practice — Addresses confidentiality, informed
consent, delegation, scope of practice, advocacy, and professional accountability.
8. Prioritization and Emergency Recognition — Develops the ability to identify unstable
patients, recognize deterioration, and determine which intervention should occur first.
Questions 1–100
Question 1: A nurse receives handoff for four patients. Which patient should the nurse assess
first?
A) A patient requesting assistance with bathing
B) A patient with new-onset shortness of breath and an oxygen saturation of 86%
C) A patient reporting chronic back pain rated 5 out of 10
D) A patient waiting for discharge instructions
Rationale: The correct answer is B because new-onset dyspnea with oxygen saturation of 86%
indicates impaired oxygenation and requires immediate assessment and intervention. Airway
and breathing concerns take priority over routine care, chronic discomfort, or discharge
teaching. Option A is important but not urgent. Option C describes a chronic problem without
evidence of acute deterioration. Option D can safely be delayed until the patient's immediate
physiologic needs are addressed.**
Question 2: During a focused respiratory assessment, which finding requires the most
immediate nursing action?
A) Respiratory rate of 20 breaths/minute
B) Clear breath sounds bilaterally
C) New inspiratory stridor
D) Mild occasional cough
Rationale: Stridor suggests upper-airway obstruction and can rapidly progress to respiratory
failure. The nurse should immediately assess airway patency and initiate appropriate emergency
measures. A respiratory rate of 20 is generally within the expected adult range, while clear
breath sounds are reassuring. An occasional mild cough is less concerning without other signs
of deterioration.**
Question 3: A patient becomes dizzy when standing from a bed. What should the nurse do first?
A) Encourage the patient to walk slowly
B) Obtain a meal tray
C) Assist the patient back to a safe sitting or lying position
D) Document the episode and continue rounds
Rationale: The immediate priority is preventing injury from a possible fall. The patient should
be safely returned to a sitting or lying position before further assessment. Encouraging
,Page |3
ambulation could increase fall risk. Obtaining food does not address the immediate safety
concern. Documentation is necessary but should occur after the patient is safe and assessed.**
Question 4: Which assessment finding most strongly indicates a risk for pressure injury?
A) Warm hands
B) Limited mobility with prolonged pressure over a bony prominence
C) Normal oral intake
D) Independent ambulation
Rationale: Prolonged pressure, particularly over bony prominences, impairs tissue perfusion
and increases pressure-injury risk. Limited mobility further increases the duration of pressure.
Warm hands and independent mobility do not independently indicate high risk. Adequate oral
intake may actually support skin integrity when nutritional needs are met.**
Question 5: A nurse is preparing to administer medication. Which action is most important for
preventing a medication error?
A) Asking another patient to confirm the patient's name
B) Using two approved patient identifiers before administration
C) Preparing all medications for the entire shift at once
D) Leaving prepared medications unattended at the bedside
Rationale: Two approved identifiers help ensure that the medication is given to the correct
patient. Patient identification is a fundamental medication-safety practice. Another patient
cannot safely verify identity. Preparing medications too far in advance increases the risk of
confusion or contamination, and medications should not be left unattended.**
Question 6: Which nursing action best demonstrates therapeutic communication?
A) “You should not worry about this.”
B) “Everything will definitely be fine.”
C) “Tell me what concerns you most about your treatment.”
D) “I know exactly how you feel.”
Rationale: The correct response uses an open-ended statement that encourages the patient to
express concerns. False reassurance can minimize feelings, and claiming to know exactly how
another person feels may block communication. Therapeutic communication focuses on the
patient's experience rather than imposing assumptions.**
Question 7: A patient refuses a prescribed treatment after receiving an explanation of its purpose
and risks. What is the nurse's best action?
A) Administer the treatment because it was prescribed
B) Ask the family to force compliance
C) Respect the refusal, assess the patient's understanding, and notify the appropriate
, Page |4
provider
D) Document that the patient is noncompliant and end the discussion
Rationale: Competent patients have the right to participate in decisions about their care,
including refusing treatment. The nurse should verify understanding, provide appropriate
information, document the refusal, and communicate with the healthcare team. Forcing
treatment violates patient autonomy. Labeling the patient simply as noncompliant does not
adequately address the clinical situation.**
Question 8: Which finding should cause the nurse to suspect dehydration?
A) Moist mucous membranes
B) Clear urine with adequate output
C) Dry mucous membranes with concentrated urine and increased thirst
D) Stable daily weight
Rationale: Dry mucous membranes, concentrated urine, and thirst are common findings
associated with inadequate fluid volume. Moist mucous membranes and adequate urine output
are less consistent with dehydration. Stable weight does not support an acute fluid deficit.**
Question 9: A patient is at high risk for falls. Which intervention is most appropriate?
A) Keep the room completely dark at night
B) Place frequently used items out of reach
C) Keep the bed in a low position and ensure the call light is accessible
D) Encourage the patient to get up independently to maintain strength
Rationale: A low bed and accessible call light reduce the likelihood of injury and allow the
patient to request assistance. Darkness can increase fall risk, and needed items should be within
safe reach. High-risk patients should not be encouraged to ambulate independently without
appropriate assessment and assistance.**
Question 10: Which action is most appropriate when documenting a patient's assessment?
A) Document assumptions about why the patient is behaving differently
B) Record information later from memory
C) Document objective findings promptly and accurately
D) Delete an incorrect entry from the legal health record
Rationale: Documentation should be timely, factual, objective, and accurate. Nurses should
avoid assumptions and should not document from memory when immediate documentation is
possible. Errors in a legal record should be corrected according to organizational policy rather
than deleted in a way that obscures the original entry.**
Question 11: A nurse observes redness over a patient's sacral area that does not disappear when
pressure is relieved. What is the priority intervention?
NU 136 EXAM 2 QUESTIONS WITH RATIONALES ACTUAL
EXAM [ QUESTION 1- 200] AND ANSWERS UPDATED 2026/2027|
100% VERIFIED|DETAILED RATIONALES –PASS GUARANTEED
A+ GRADED |INSTANT DOWNLOAD
Introduction:
NU 136 Exam 2 is designed as an original, comprehensive practice resource to help nursing
students strengthen their clinical reasoning, assessment, prioritization, communication, safety,
and evidence-based nursing knowledge. This practice set uses scenario-based questions that
require students to apply concepts rather than simply recall definitions. The questions are
structured to resemble the level of reasoning commonly expected in nursing examinations,
while remaining original study material rather than reproduced examination questions or a
brain dump. The set emphasizes recognizing relevant assessment findings, identifying
priorities, selecting appropriate nursing interventions, evaluating outcomes, and
distinguishing expected findings from those requiring immediate action. Detailed rationales
are provided after every question so learners can understand not only which option is best, but
also why the alternatives are less appropriate. Students can use the questions for independent
revision, classroom preparation, or timed practice. Repeated review of the rationales can help
identify knowledge gaps, improve clinical judgment, and build confidence before an
examination.
Core Domains Covered:
1. Health Assessment and Clinical Data Interpretation — Applies systematic assessment
techniques, recognizes significant findings, and distinguishes expected from abnormal data.
2. Nursing Process and Clinical Judgment — Focuses on assessment, nursing diagnoses,
planning, implementation, evaluation, and prioritization of patient needs.
3. Safety and Infection Prevention — Covers standard precautions, transmission-based
precautions, environmental safety, fall prevention, and prevention of healthcare-associated
infections.
4. Fundamentals of Patient Care — Addresses hygiene, mobility, positioning, nutrition,
elimination, comfort, skin integrity, and basic nursing interventions.
5. Communication and Therapeutic Relationships — Emphasizes therapeutic communication,
patient education, professional boundaries, cultural considerations, and effective
documentation.
6. Medication and Treatment Safety — Covers medication administration principles, adverse
effects, patient identification, monitoring, and prevention of medication errors.
,Page |2
7. Ethical, Legal, and Professional Nursing Practice — Addresses confidentiality, informed
consent, delegation, scope of practice, advocacy, and professional accountability.
8. Prioritization and Emergency Recognition — Develops the ability to identify unstable
patients, recognize deterioration, and determine which intervention should occur first.
Questions 1–100
Question 1: A nurse receives handoff for four patients. Which patient should the nurse assess
first?
A) A patient requesting assistance with bathing
B) A patient with new-onset shortness of breath and an oxygen saturation of 86%
C) A patient reporting chronic back pain rated 5 out of 10
D) A patient waiting for discharge instructions
Rationale: The correct answer is B because new-onset dyspnea with oxygen saturation of 86%
indicates impaired oxygenation and requires immediate assessment and intervention. Airway
and breathing concerns take priority over routine care, chronic discomfort, or discharge
teaching. Option A is important but not urgent. Option C describes a chronic problem without
evidence of acute deterioration. Option D can safely be delayed until the patient's immediate
physiologic needs are addressed.**
Question 2: During a focused respiratory assessment, which finding requires the most
immediate nursing action?
A) Respiratory rate of 20 breaths/minute
B) Clear breath sounds bilaterally
C) New inspiratory stridor
D) Mild occasional cough
Rationale: Stridor suggests upper-airway obstruction and can rapidly progress to respiratory
failure. The nurse should immediately assess airway patency and initiate appropriate emergency
measures. A respiratory rate of 20 is generally within the expected adult range, while clear
breath sounds are reassuring. An occasional mild cough is less concerning without other signs
of deterioration.**
Question 3: A patient becomes dizzy when standing from a bed. What should the nurse do first?
A) Encourage the patient to walk slowly
B) Obtain a meal tray
C) Assist the patient back to a safe sitting or lying position
D) Document the episode and continue rounds
Rationale: The immediate priority is preventing injury from a possible fall. The patient should
be safely returned to a sitting or lying position before further assessment. Encouraging
,Page |3
ambulation could increase fall risk. Obtaining food does not address the immediate safety
concern. Documentation is necessary but should occur after the patient is safe and assessed.**
Question 4: Which assessment finding most strongly indicates a risk for pressure injury?
A) Warm hands
B) Limited mobility with prolonged pressure over a bony prominence
C) Normal oral intake
D) Independent ambulation
Rationale: Prolonged pressure, particularly over bony prominences, impairs tissue perfusion
and increases pressure-injury risk. Limited mobility further increases the duration of pressure.
Warm hands and independent mobility do not independently indicate high risk. Adequate oral
intake may actually support skin integrity when nutritional needs are met.**
Question 5: A nurse is preparing to administer medication. Which action is most important for
preventing a medication error?
A) Asking another patient to confirm the patient's name
B) Using two approved patient identifiers before administration
C) Preparing all medications for the entire shift at once
D) Leaving prepared medications unattended at the bedside
Rationale: Two approved identifiers help ensure that the medication is given to the correct
patient. Patient identification is a fundamental medication-safety practice. Another patient
cannot safely verify identity. Preparing medications too far in advance increases the risk of
confusion or contamination, and medications should not be left unattended.**
Question 6: Which nursing action best demonstrates therapeutic communication?
A) “You should not worry about this.”
B) “Everything will definitely be fine.”
C) “Tell me what concerns you most about your treatment.”
D) “I know exactly how you feel.”
Rationale: The correct response uses an open-ended statement that encourages the patient to
express concerns. False reassurance can minimize feelings, and claiming to know exactly how
another person feels may block communication. Therapeutic communication focuses on the
patient's experience rather than imposing assumptions.**
Question 7: A patient refuses a prescribed treatment after receiving an explanation of its purpose
and risks. What is the nurse's best action?
A) Administer the treatment because it was prescribed
B) Ask the family to force compliance
C) Respect the refusal, assess the patient's understanding, and notify the appropriate
, Page |4
provider
D) Document that the patient is noncompliant and end the discussion
Rationale: Competent patients have the right to participate in decisions about their care,
including refusing treatment. The nurse should verify understanding, provide appropriate
information, document the refusal, and communicate with the healthcare team. Forcing
treatment violates patient autonomy. Labeling the patient simply as noncompliant does not
adequately address the clinical situation.**
Question 8: Which finding should cause the nurse to suspect dehydration?
A) Moist mucous membranes
B) Clear urine with adequate output
C) Dry mucous membranes with concentrated urine and increased thirst
D) Stable daily weight
Rationale: Dry mucous membranes, concentrated urine, and thirst are common findings
associated with inadequate fluid volume. Moist mucous membranes and adequate urine output
are less consistent with dehydration. Stable weight does not support an acute fluid deficit.**
Question 9: A patient is at high risk for falls. Which intervention is most appropriate?
A) Keep the room completely dark at night
B) Place frequently used items out of reach
C) Keep the bed in a low position and ensure the call light is accessible
D) Encourage the patient to get up independently to maintain strength
Rationale: A low bed and accessible call light reduce the likelihood of injury and allow the
patient to request assistance. Darkness can increase fall risk, and needed items should be within
safe reach. High-risk patients should not be encouraged to ambulate independently without
appropriate assessment and assistance.**
Question 10: Which action is most appropriate when documenting a patient's assessment?
A) Document assumptions about why the patient is behaving differently
B) Record information later from memory
C) Document objective findings promptly and accurately
D) Delete an incorrect entry from the legal health record
Rationale: Documentation should be timely, factual, objective, and accurate. Nurses should
avoid assumptions and should not document from memory when immediate documentation is
possible. Errors in a legal record should be corrected according to organizational policy rather
than deleted in a way that obscures the original entry.**
Question 11: A nurse observes redness over a patient's sacral area that does not disappear when
pressure is relieved. What is the priority intervention?
