,NU 136 - Fundamentals of Nursing Exam 1 Questions
and Answers with Rationale 2026/2027 Update
Question 1: The Nursing Process (Assessment vs.
Implementation)
A nurse is caring for a newly admitted client who reports severe
right lower quadrant abdominal pain. Which of the following
actions should the nurse take first?
A. Administer the prescribed PRN analgesic medication.
B. Auscultate bowel sounds in all four quadrants.
C. Document the client's pain score in the electronic medical
record.
D. Apply a warm compress to the client's abdomen.
Correct Answer: B. Auscultate bowel sounds in all four
quadrants.
Expert Rationale: According to the nursing process,
assessment must always precede implementation (such as
administering medication or applying heat). Auscultating the
abdomen before palpating or intervening prevents altering bowel
sounds and gathers baseline clinical data.
Question 2: Vital Signs (Orthostatic Hypotension
Assessment)
A nurse is preparing to assess a client for orthostatic
hypotension. Which of the following actions is appropriate for
the nurse to take?
, A. Measure the client's blood pressure and heart rate
immediately after the client stands up from a lying position.
B. Have the client lie supine for 10 minutes, measure blood
pressure and heart rate, then repeat measurements within 1
to 3 minutes of standing.
C. Measure blood pressure in the right arm while the client is
sitting, then immediately in the left arm while standing.
D. Check the blood pressure only if the client reports severe
dizziness upon sudden rising.
Correct Answer: B. Have the client lie supine for 10 minutes,
measure blood pressure and heart rate, then repeat
measurements within 1 to 3 minutes of standing.
Expert Rationale: Accurate orthostatic assessment requires a
baseline blood pressure and pulse obtained after the client has
rested supine (or seated) for several minutes. Measurements are
then repeated sequentially after the client moves to a standing
position to check for a drop in systolic pressure or diastolic
pressure accompanied by pulse changes.
Question 3: Infection Control (Standard vs. Transmission-
Based Precautions)
A nurse is caring for a client diagnosed with Clostridioides
difficile (C. diff). Which type of infection control precautions
should the nurse implement?
A. Airborne precautions in a negative-pressure room
B. Droplet precautions with a surgical mask
, C. Contact precautions requiring gown and gloves, using soap
and water for hand hygiene
D. Protective reverse isolation
Correct Answer: C. Contact precautions requiring gown and
gloves, using soap and water for hand hygiene
Expert Rationale: Clostridioides difficile produces spores that
are resistant to alcohol-based hand sanitizers. Therefore, nurses
and visitors must adhere to contact precautions and perform
hand hygiene using soap and water to physically remove the
spores from hands.
Question 4: Medication Administration (Z-Track Method)
A nurse is preparing to administer an intramuscular injection
using the Z-track technique. What is the primary rationale for
using this method?
A. To increase the rate of drug absorption into subcutaneous
fat.
B. To prevent medication from leaking back into the
subcutaneous tissue and causing skin irritation or staining.
C. To eliminate the need to aspirate before injecting the
solution.
D. To decrease the required needle length for pediatric clients.
Correct Answer: B. To prevent medication from leaking
back into the subcutaneous tissue and causing skin irritation
or staining.
and Answers with Rationale 2026/2027 Update
Question 1: The Nursing Process (Assessment vs.
Implementation)
A nurse is caring for a newly admitted client who reports severe
right lower quadrant abdominal pain. Which of the following
actions should the nurse take first?
A. Administer the prescribed PRN analgesic medication.
B. Auscultate bowel sounds in all four quadrants.
C. Document the client's pain score in the electronic medical
record.
D. Apply a warm compress to the client's abdomen.
Correct Answer: B. Auscultate bowel sounds in all four
quadrants.
Expert Rationale: According to the nursing process,
assessment must always precede implementation (such as
administering medication or applying heat). Auscultating the
abdomen before palpating or intervening prevents altering bowel
sounds and gathers baseline clinical data.
Question 2: Vital Signs (Orthostatic Hypotension
Assessment)
A nurse is preparing to assess a client for orthostatic
hypotension. Which of the following actions is appropriate for
the nurse to take?
, A. Measure the client's blood pressure and heart rate
immediately after the client stands up from a lying position.
B. Have the client lie supine for 10 minutes, measure blood
pressure and heart rate, then repeat measurements within 1
to 3 minutes of standing.
C. Measure blood pressure in the right arm while the client is
sitting, then immediately in the left arm while standing.
D. Check the blood pressure only if the client reports severe
dizziness upon sudden rising.
Correct Answer: B. Have the client lie supine for 10 minutes,
measure blood pressure and heart rate, then repeat
measurements within 1 to 3 minutes of standing.
Expert Rationale: Accurate orthostatic assessment requires a
baseline blood pressure and pulse obtained after the client has
rested supine (or seated) for several minutes. Measurements are
then repeated sequentially after the client moves to a standing
position to check for a drop in systolic pressure or diastolic
pressure accompanied by pulse changes.
Question 3: Infection Control (Standard vs. Transmission-
Based Precautions)
A nurse is caring for a client diagnosed with Clostridioides
difficile (C. diff). Which type of infection control precautions
should the nurse implement?
A. Airborne precautions in a negative-pressure room
B. Droplet precautions with a surgical mask
, C. Contact precautions requiring gown and gloves, using soap
and water for hand hygiene
D. Protective reverse isolation
Correct Answer: C. Contact precautions requiring gown and
gloves, using soap and water for hand hygiene
Expert Rationale: Clostridioides difficile produces spores that
are resistant to alcohol-based hand sanitizers. Therefore, nurses
and visitors must adhere to contact precautions and perform
hand hygiene using soap and water to physically remove the
spores from hands.
Question 4: Medication Administration (Z-Track Method)
A nurse is preparing to administer an intramuscular injection
using the Z-track technique. What is the primary rationale for
using this method?
A. To increase the rate of drug absorption into subcutaneous
fat.
B. To prevent medication from leaking back into the
subcutaneous tissue and causing skin irritation or staining.
C. To eliminate the need to aspirate before injecting the
solution.
D. To decrease the required needle length for pediatric clients.
Correct Answer: B. To prevent medication from leaking
back into the subcutaneous tissue and causing skin irritation
or staining.
