NU 136 EXAM 2 ULTIMATE REVIEW — QUESTIONS 1–
100 AND ANSWERS | UPDATED 2026/2027 | DETAILED
RATIONALES
Introduction:
**This NU 136 Exam 2 Ultimate Review provides 100 original, exam-level practice questions
covering major concepts associated with the second examination. The review emphasizes clinical
judgment, prioritization, assessment, patient safety, nursing interventions, and evaluation of
outcomes rather than simple memorization. Major areas include respiratory assessment and
priority care; musculoskeletal assessment and mobility; wounds and pressure injuries; urinary
elimination and catheter care; urinary diversions and stoma management; constipation and
diarrhea; hydration and electrolyte considerations; and bowel assessment and specimen
collection. The questions are designed to help learners recognize important assessment findings,
distinguish expected from unexpected findings, select appropriate nursing interventions, and
identify which patient requires immediate attention. Each question includes one best answer
followed by a rationale explaining the clinical reasoning and why the alternatives are less
appropriate. Use the set as a structured study resource: answer each question independently
first, then review the rationale and identify the principle being tested. Repeated practice with
prioritization and application questions can strengthen clinical reasoning and preparation for
nursing examinations.**
Core Domains Covered:
1. Respiratory Assessment and Management — Assessment of respiratory status, oxygenation,
breath sounds, airway concerns, and priority nursing interventions.
2. Musculoskeletal Assessment and Mobility — Neurovascular assessment, fractures, casts,
traction, mobility devices, and prevention of complications.
3. Wound and Pressure-Injury Care — Wound assessment, pressure-injury prevention and
management, dressing care, infection recognition, and skin protection.
4. Urinary Elimination — Urinary assessment, retention, infection prevention, catheter care,
specimen collection, and patient education.
5. Urinary Diversions — Stoma assessment, urine characteristics, peristomal skin care,
appliance management, and recognition of complications.
6. Bowel Elimination — Constipation, diarrhea, bowel assessment, interventions, medications,
and patient education.
**7. Hydration, Electrolytes, and Specimen Management — Fluid balance, dehydration risks,
monitoring, and appropriate collection of urinary and gastrointestinal specimens.**
,QUESTIONS 1–100
Question 1
A nurse assesses a patient who suddenly develops shortness of breath and restlessness. The
respiratory rate is 30/min, and the patient has difficulty speaking in complete sentences. Which
action should the nurse take first?
A) Encourage the patient to drink fluids
B) Assess airway patency and oxygenation immediately
C) Obtain a detailed nutritional history
D) Place the patient in a supine position
Rationale: Airway and breathing are immediate priorities when a patient develops acute
respiratory distress. Assessing airway patency and oxygenation allows the nurse to identify life-
threatening deterioration rapidly. Fluids and nutritional assessment do not address the
immediate problem. A supine position may worsen ventilation in a patient experiencing
respiratory distress; positioning should generally promote lung expansion.
Question 2
During respiratory assessment, which finding requires the most immediate follow-up?
A) Respiratory rate of 18/min
B) Symmetrical chest expansion
C) New-onset cyanosis around the lips
D) Clear bilateral breath sounds
Rationale: New cyanosis may indicate significant oxygenation impairment and requires prompt
assessment and intervention. A normal respiratory rate, symmetrical expansion, and clear breath
sounds are generally reassuring findings. The nurse should investigate the cause of cyanosis and
assess oxygen saturation and overall respiratory status.
Question 3
A patient with respiratory difficulty is sitting upright and leaning forward with the arms
supported on a bedside table. What is the nurse's best interpretation?
A) The patient is demonstrating a normal resting position
B) The patient is using positioning to facilitate breathing
C) The patient is demonstrating impaired circulation
D) The patient is preparing for ambulation
Rationale: Upright positioning with forward support can help accessory respiratory muscles
function more effectively and may improve ventilation. This posture can occur when a patient is
,experiencing respiratory distress. It should prompt continued respiratory assessment rather than
being dismissed as ordinary positioning.
Question 4
A nurse hears wheezing during auscultation of a patient's lungs. Which interpretation is most
appropriate?
A) Complete absence of airflow
B) Airflow through narrowed airways
C) Fluid exclusively within the pleural cavity
D) Normal airflow through large airways
Rationale: Wheezing is commonly associated with narrowed airways and may occur with
bronchospasm or airway inflammation. Complete absence of airflow would be more concerning
for severe obstruction or markedly reduced ventilation. Pleural fluid produces different
assessment findings, and wheezing is not considered a normal breath sound.
Question 5
Which respiratory assessment finding should the nurse report promptly?
A) Respiratory rate of 16/min
B) Clear breath sounds bilaterally
C) Oxygen saturation consistent with the patient's established baseline
D) Increasing respiratory effort with new confusion
Rationale: Increasing work of breathing combined with new confusion may indicate inadequate
oxygenation or worsening respiratory compromise. The combination is particularly concerning
because neurological changes can occur with impaired oxygen delivery. The other findings are
not inherently abnormal when consistent with the patient's baseline.
Question 6
A nurse is caring for a patient who is having difficulty breathing. Which position generally
promotes lung expansion most effectively?
A) Flat supine
B) Trendelenburg
C) High-Fowler's position
D) Prone with the head turned downward
Rationale: High-Fowler's positioning elevates the upper body and can facilitate diaphragmatic
movement and lung expansion. Supine and Trendelenburg positioning may compromise
ventilation in some patients. Position should always be individualized according to the patient's
condition.
, Question 7
A patient reports that breathing becomes difficult when lying flat. How should the nurse
document this symptom?
A) Bradypnea
B) Apnea
C) Orthopnea
D) Hyperpnea
Rationale: Orthopnea refers to difficulty breathing when lying flat that improves when the
patient sits or stands. Bradypnea means an abnormally slow respiratory rate, apnea means
absence of breathing, and hyperpnea refers to increased depth of breathing.
Question 8
Which assessment is most useful when evaluating a patient with suspected respiratory
deterioration?
A) Hair and scalp assessment
B) Abdominal circumference only
C) Respiratory rate, effort, oxygen saturation, and breath sounds
D) Dietary preferences
Rationale: Respiratory rate, work of breathing, oxygen saturation, and auscultation provide
direct information about ventilation and oxygenation. A focused respiratory assessment should
be performed when respiratory deterioration is suspected.
Question 9
A nurse notices that a patient with respiratory distress is becoming increasingly drowsy. What
should the nurse recognize?
A) Drowsiness always indicates improved comfort
B) The finding is unrelated to respiratory status
C) Altered level of consciousness can indicate worsening oxygenation or ventilation
D) The patient should immediately be encouraged to walk
Rationale: Neurological changes can accompany inadequate oxygenation or impaired
ventilation and should be treated as potentially significant. Increasing drowsiness in a patient
with respiratory distress warrants immediate reassessment and escalation as appropriate.
Ambulation is inappropriate until the patient's respiratory status is stabilized.
Question 10
100 AND ANSWERS | UPDATED 2026/2027 | DETAILED
RATIONALES
Introduction:
**This NU 136 Exam 2 Ultimate Review provides 100 original, exam-level practice questions
covering major concepts associated with the second examination. The review emphasizes clinical
judgment, prioritization, assessment, patient safety, nursing interventions, and evaluation of
outcomes rather than simple memorization. Major areas include respiratory assessment and
priority care; musculoskeletal assessment and mobility; wounds and pressure injuries; urinary
elimination and catheter care; urinary diversions and stoma management; constipation and
diarrhea; hydration and electrolyte considerations; and bowel assessment and specimen
collection. The questions are designed to help learners recognize important assessment findings,
distinguish expected from unexpected findings, select appropriate nursing interventions, and
identify which patient requires immediate attention. Each question includes one best answer
followed by a rationale explaining the clinical reasoning and why the alternatives are less
appropriate. Use the set as a structured study resource: answer each question independently
first, then review the rationale and identify the principle being tested. Repeated practice with
prioritization and application questions can strengthen clinical reasoning and preparation for
nursing examinations.**
Core Domains Covered:
1. Respiratory Assessment and Management — Assessment of respiratory status, oxygenation,
breath sounds, airway concerns, and priority nursing interventions.
2. Musculoskeletal Assessment and Mobility — Neurovascular assessment, fractures, casts,
traction, mobility devices, and prevention of complications.
3. Wound and Pressure-Injury Care — Wound assessment, pressure-injury prevention and
management, dressing care, infection recognition, and skin protection.
4. Urinary Elimination — Urinary assessment, retention, infection prevention, catheter care,
specimen collection, and patient education.
5. Urinary Diversions — Stoma assessment, urine characteristics, peristomal skin care,
appliance management, and recognition of complications.
6. Bowel Elimination — Constipation, diarrhea, bowel assessment, interventions, medications,
and patient education.
**7. Hydration, Electrolytes, and Specimen Management — Fluid balance, dehydration risks,
monitoring, and appropriate collection of urinary and gastrointestinal specimens.**
,QUESTIONS 1–100
Question 1
A nurse assesses a patient who suddenly develops shortness of breath and restlessness. The
respiratory rate is 30/min, and the patient has difficulty speaking in complete sentences. Which
action should the nurse take first?
A) Encourage the patient to drink fluids
B) Assess airway patency and oxygenation immediately
C) Obtain a detailed nutritional history
D) Place the patient in a supine position
Rationale: Airway and breathing are immediate priorities when a patient develops acute
respiratory distress. Assessing airway patency and oxygenation allows the nurse to identify life-
threatening deterioration rapidly. Fluids and nutritional assessment do not address the
immediate problem. A supine position may worsen ventilation in a patient experiencing
respiratory distress; positioning should generally promote lung expansion.
Question 2
During respiratory assessment, which finding requires the most immediate follow-up?
A) Respiratory rate of 18/min
B) Symmetrical chest expansion
C) New-onset cyanosis around the lips
D) Clear bilateral breath sounds
Rationale: New cyanosis may indicate significant oxygenation impairment and requires prompt
assessment and intervention. A normal respiratory rate, symmetrical expansion, and clear breath
sounds are generally reassuring findings. The nurse should investigate the cause of cyanosis and
assess oxygen saturation and overall respiratory status.
Question 3
A patient with respiratory difficulty is sitting upright and leaning forward with the arms
supported on a bedside table. What is the nurse's best interpretation?
A) The patient is demonstrating a normal resting position
B) The patient is using positioning to facilitate breathing
C) The patient is demonstrating impaired circulation
D) The patient is preparing for ambulation
Rationale: Upright positioning with forward support can help accessory respiratory muscles
function more effectively and may improve ventilation. This posture can occur when a patient is
,experiencing respiratory distress. It should prompt continued respiratory assessment rather than
being dismissed as ordinary positioning.
Question 4
A nurse hears wheezing during auscultation of a patient's lungs. Which interpretation is most
appropriate?
A) Complete absence of airflow
B) Airflow through narrowed airways
C) Fluid exclusively within the pleural cavity
D) Normal airflow through large airways
Rationale: Wheezing is commonly associated with narrowed airways and may occur with
bronchospasm or airway inflammation. Complete absence of airflow would be more concerning
for severe obstruction or markedly reduced ventilation. Pleural fluid produces different
assessment findings, and wheezing is not considered a normal breath sound.
Question 5
Which respiratory assessment finding should the nurse report promptly?
A) Respiratory rate of 16/min
B) Clear breath sounds bilaterally
C) Oxygen saturation consistent with the patient's established baseline
D) Increasing respiratory effort with new confusion
Rationale: Increasing work of breathing combined with new confusion may indicate inadequate
oxygenation or worsening respiratory compromise. The combination is particularly concerning
because neurological changes can occur with impaired oxygen delivery. The other findings are
not inherently abnormal when consistent with the patient's baseline.
Question 6
A nurse is caring for a patient who is having difficulty breathing. Which position generally
promotes lung expansion most effectively?
A) Flat supine
B) Trendelenburg
C) High-Fowler's position
D) Prone with the head turned downward
Rationale: High-Fowler's positioning elevates the upper body and can facilitate diaphragmatic
movement and lung expansion. Supine and Trendelenburg positioning may compromise
ventilation in some patients. Position should always be individualized according to the patient's
condition.
, Question 7
A patient reports that breathing becomes difficult when lying flat. How should the nurse
document this symptom?
A) Bradypnea
B) Apnea
C) Orthopnea
D) Hyperpnea
Rationale: Orthopnea refers to difficulty breathing when lying flat that improves when the
patient sits or stands. Bradypnea means an abnormally slow respiratory rate, apnea means
absence of breathing, and hyperpnea refers to increased depth of breathing.
Question 8
Which assessment is most useful when evaluating a patient with suspected respiratory
deterioration?
A) Hair and scalp assessment
B) Abdominal circumference only
C) Respiratory rate, effort, oxygen saturation, and breath sounds
D) Dietary preferences
Rationale: Respiratory rate, work of breathing, oxygen saturation, and auscultation provide
direct information about ventilation and oxygenation. A focused respiratory assessment should
be performed when respiratory deterioration is suspected.
Question 9
A nurse notices that a patient with respiratory distress is becoming increasingly drowsy. What
should the nurse recognize?
A) Drowsiness always indicates improved comfort
B) The finding is unrelated to respiratory status
C) Altered level of consciousness can indicate worsening oxygenation or ventilation
D) The patient should immediately be encouraged to walk
Rationale: Neurological changes can accompany inadequate oxygenation or impaired
ventilation and should be treated as potentially significant. Increasing drowsiness in a patient
with respiratory distress warrants immediate reassessment and escalation as appropriate.
Ambulation is inappropriate until the patient's respiratory status is stabilized.
Question 10
