NU136 EXAM 4 | NU 136 FUNDAMENTALS OF NURSING EXAM | EXAM PRACTICE |
STUDY GUIDE | TESTBANK | PRACTICE QUESTIONS & ANSWERS | EXAM
PREPARATION | ADVANCED REVIEW | COMPREHENSIVE PRACTICE EXAM | LATEST
UPDATE 2026/2027
Examiner:
School/College of Nursing (NU136 Fundamentals of Nursing Course)
TABLE OF CONTENTS
1. Infection Prevention and Standard Precautions
2. Medication Administration and Safety
3. Clinical Judgment and Nursing Process
4. Documentation and Legal/Ethical Nursing Practice
5. Patient Safety and Quality Improvement
6. Fluid and Electrolyte Balance
7. Mobility, Positioning, and Fall Prevention
8. Oxygenation and Respiratory Care
9. Nutrition and Elimination
10. Pain Assessment and Comfort Measures
11. Communication and Patient Education
12. Delegation and Prioritization
NURSING FUNDAMENTALS || CLINICAL JUDGMENT || PATIENT SAFETY || STANDARD
PRECAUTIONS || MEDICATION SAFETY || NURSING PROCESS || DOCUMENTATION ||
ETHICS || DELEGATION || PRIORITIZATION || INFECTION CONTROL || OXYGENATION
|| FLUID BALANCE || ELIMINATION || MOBILITY || PAIN MANAGEMENT || HEALTH
ASSESSMENT || QUALITY IMPROVEMENT || EXAM PREPARATION || ADVANCED
REVIEW
QUESTION 1.
A postoperative patient develops increasing confusion, tachycardia, and hypotension
two hours after surgery. Which nursing action best reflects the priority established by
the nursing process?
,A. Assess airway, breathing, circulation, and obtain a complete set of vital signs.
B. Document the patient's change in condition before intervening.
C. Administer the prescribed PRN analgesic.
D. Encourage oral fluids and reassess in one hour.
🔴 Correct Answer: A. Assess airway, breathing, circulation, and obtain a complete
set of vital signs.
🔵 Explanation: Immediate assessment using the ABC framework is the priority because
the patient's condition suggests potential postoperative complications requiring rapid
intervention. Documentation occurs after assessment and interventions. Pain medication
may worsen hypotension or altered mental status, and delaying intervention by
encouraging oral fluids is inappropriate.
QUESTION 2.
A nurse prepares to administer insulin to a patient with a current blood glucose of 62
mg/dL who is alert and able to swallow. Which action is most appropriate?
A. Administer insulin as prescribed because it is scheduled.
B. Hold the insulin, treat the hypoglycemia according to protocol, and notify the
provider if indicated.
C. Delay insulin administration until bedtime.
D. Administer half the insulin dose without notifying anyone.
🔴 Correct Answer: B. Hold the insulin, treat the hypoglycemia according to
protocol, and notify the provider if indicated.
🔵 Explanation: Treating symptomatic or confirmed hypoglycemia takes priority over
administering scheduled insulin. Insulin would further lower blood glucose. Arbitrarily
reducing or delaying doses without following institutional protocols is unsafe.
QUESTION 3.
Which finding requires the nurse to implement transmission-based precautions in
addition to standard precautions?
,A. Controlled hypertension
B. Stage I pressure injury
C. Confirmed pulmonary tuberculosis
D. Chronic osteoarthritis
🔴 Correct Answer: C. Confirmed pulmonary tuberculosis
🔵 Explanation: Pulmonary tuberculosis requires airborne precautions in addition to
standard precautions because the organism is transmitted through airborne particles.
The remaining conditions do not require additional transmission-based isolation
measures.
QUESTION 4.
A newly admitted patient states, "I do not want any blood products under any
circumstances." What is the nurse's priority action?
A. Explain that blood transfusions are mandatory.
B. Obtain clarification, verify documentation of the patient's wishes, and notify the
provider as appropriate.
C. Ignore the statement unless surgery becomes necessary.
D. Ask family members to override the patient's decision.
🔴 Correct Answer: B. Obtain clarification, verify documentation of the patient's
wishes, and notify the provider as appropriate.
🔵 Explanation: Respect for patient autonomy requires confirming and documenting
informed treatment preferences. Competent adults have the right to refuse treatment.
Family members cannot override competent patients' decisions.
QUESTION 5.
A nurse delegates ambulation of a stable postoperative patient to an experienced
nursing assistant. Which responsibility remains solely with the registered nurse?
A. Measuring intake and output
B. Recording the patient's weight
, C. Evaluating the patient's tolerance and modifying the care plan
D. Assisting with hygiene
🔴 Correct Answer: C. Evaluating the patient's tolerance and modifying the care
plan
🔵 Explanation: Evaluation and clinical judgment remain the responsibility of the
registered nurse even when implementation tasks are delegated. Routine tasks such as
hygiene, weights, and intake/output may be delegated according to institutional policy.
QUESTION 6.
Which documentation entry demonstrates appropriate professional documentation?
A. "Patient seemed lazy and refused therapy."
B. "Patient would not cooperate despite repeated encouragement."
C. "Patient stated, 'I am too tired to participate today,' and declined physical therapy
despite education regarding benefits."
D. "Patient has a poor attitude."
🔴 Correct Answer: C. "Patient stated, 'I am too tired to participate today,' and
declined physical therapy despite education regarding benefits."
🔵 Explanation: Objective, factual documentation including direct patient statements is
appropriate. Judgmental or subjective language such as "lazy," "poor attitude," or "would
not cooperate" should be avoided because it lacks objectivity.
QUESTION 7.
A patient receiving continuous oxygen therapy suddenly develops increasing dyspnea
and oxygen saturation decreases from 96% to 84%. Which nursing action has the
highest priority?
A. Encourage oral hydration.
B. Assess airway patency and equipment function immediately.
C. Document the oxygen saturation trend.
D. Schedule respiratory therapy for later in the day.
STUDY GUIDE | TESTBANK | PRACTICE QUESTIONS & ANSWERS | EXAM
PREPARATION | ADVANCED REVIEW | COMPREHENSIVE PRACTICE EXAM | LATEST
UPDATE 2026/2027
Examiner:
School/College of Nursing (NU136 Fundamentals of Nursing Course)
TABLE OF CONTENTS
1. Infection Prevention and Standard Precautions
2. Medication Administration and Safety
3. Clinical Judgment and Nursing Process
4. Documentation and Legal/Ethical Nursing Practice
5. Patient Safety and Quality Improvement
6. Fluid and Electrolyte Balance
7. Mobility, Positioning, and Fall Prevention
8. Oxygenation and Respiratory Care
9. Nutrition and Elimination
10. Pain Assessment and Comfort Measures
11. Communication and Patient Education
12. Delegation and Prioritization
NURSING FUNDAMENTALS || CLINICAL JUDGMENT || PATIENT SAFETY || STANDARD
PRECAUTIONS || MEDICATION SAFETY || NURSING PROCESS || DOCUMENTATION ||
ETHICS || DELEGATION || PRIORITIZATION || INFECTION CONTROL || OXYGENATION
|| FLUID BALANCE || ELIMINATION || MOBILITY || PAIN MANAGEMENT || HEALTH
ASSESSMENT || QUALITY IMPROVEMENT || EXAM PREPARATION || ADVANCED
REVIEW
QUESTION 1.
A postoperative patient develops increasing confusion, tachycardia, and hypotension
two hours after surgery. Which nursing action best reflects the priority established by
the nursing process?
,A. Assess airway, breathing, circulation, and obtain a complete set of vital signs.
B. Document the patient's change in condition before intervening.
C. Administer the prescribed PRN analgesic.
D. Encourage oral fluids and reassess in one hour.
🔴 Correct Answer: A. Assess airway, breathing, circulation, and obtain a complete
set of vital signs.
🔵 Explanation: Immediate assessment using the ABC framework is the priority because
the patient's condition suggests potential postoperative complications requiring rapid
intervention. Documentation occurs after assessment and interventions. Pain medication
may worsen hypotension or altered mental status, and delaying intervention by
encouraging oral fluids is inappropriate.
QUESTION 2.
A nurse prepares to administer insulin to a patient with a current blood glucose of 62
mg/dL who is alert and able to swallow. Which action is most appropriate?
A. Administer insulin as prescribed because it is scheduled.
B. Hold the insulin, treat the hypoglycemia according to protocol, and notify the
provider if indicated.
C. Delay insulin administration until bedtime.
D. Administer half the insulin dose without notifying anyone.
🔴 Correct Answer: B. Hold the insulin, treat the hypoglycemia according to
protocol, and notify the provider if indicated.
🔵 Explanation: Treating symptomatic or confirmed hypoglycemia takes priority over
administering scheduled insulin. Insulin would further lower blood glucose. Arbitrarily
reducing or delaying doses without following institutional protocols is unsafe.
QUESTION 3.
Which finding requires the nurse to implement transmission-based precautions in
addition to standard precautions?
,A. Controlled hypertension
B. Stage I pressure injury
C. Confirmed pulmonary tuberculosis
D. Chronic osteoarthritis
🔴 Correct Answer: C. Confirmed pulmonary tuberculosis
🔵 Explanation: Pulmonary tuberculosis requires airborne precautions in addition to
standard precautions because the organism is transmitted through airborne particles.
The remaining conditions do not require additional transmission-based isolation
measures.
QUESTION 4.
A newly admitted patient states, "I do not want any blood products under any
circumstances." What is the nurse's priority action?
A. Explain that blood transfusions are mandatory.
B. Obtain clarification, verify documentation of the patient's wishes, and notify the
provider as appropriate.
C. Ignore the statement unless surgery becomes necessary.
D. Ask family members to override the patient's decision.
🔴 Correct Answer: B. Obtain clarification, verify documentation of the patient's
wishes, and notify the provider as appropriate.
🔵 Explanation: Respect for patient autonomy requires confirming and documenting
informed treatment preferences. Competent adults have the right to refuse treatment.
Family members cannot override competent patients' decisions.
QUESTION 5.
A nurse delegates ambulation of a stable postoperative patient to an experienced
nursing assistant. Which responsibility remains solely with the registered nurse?
A. Measuring intake and output
B. Recording the patient's weight
, C. Evaluating the patient's tolerance and modifying the care plan
D. Assisting with hygiene
🔴 Correct Answer: C. Evaluating the patient's tolerance and modifying the care
plan
🔵 Explanation: Evaluation and clinical judgment remain the responsibility of the
registered nurse even when implementation tasks are delegated. Routine tasks such as
hygiene, weights, and intake/output may be delegated according to institutional policy.
QUESTION 6.
Which documentation entry demonstrates appropriate professional documentation?
A. "Patient seemed lazy and refused therapy."
B. "Patient would not cooperate despite repeated encouragement."
C. "Patient stated, 'I am too tired to participate today,' and declined physical therapy
despite education regarding benefits."
D. "Patient has a poor attitude."
🔴 Correct Answer: C. "Patient stated, 'I am too tired to participate today,' and
declined physical therapy despite education regarding benefits."
🔵 Explanation: Objective, factual documentation including direct patient statements is
appropriate. Judgmental or subjective language such as "lazy," "poor attitude," or "would
not cooperate" should be avoided because it lacks objectivity.
QUESTION 7.
A patient receiving continuous oxygen therapy suddenly develops increasing dyspnea
and oxygen saturation decreases from 96% to 84%. Which nursing action has the
highest priority?
A. Encourage oral hydration.
B. Assess airway patency and equipment function immediately.
C. Document the oxygen saturation trend.
D. Schedule respiratory therapy for later in the day.
