, NU 136: Fundamentals of Nursing Exam 3
Questions and Answers with Rationale
2026/2027 Update
Question 1: Clinical Judgement & The Nursing Process
(Assessment Phase)
A newly admitted client is assessed by a nurse who notes a
reddened, non-blanchable area over the sacrum. How should the
nurse correctly document and classify this initial finding within
the nursing process framework?
A. As a nursing diagnosis of Impaired Skin Integrity
B. As objective subjective data reflecting a Stage 1 Pressure
Injury
C. As an evaluation outcome measurement
D. As a dependent medical intervention order
Correct Answer: B. As objective subjective data reflecting a
Stage 1 Pressure Injury
Expert Rationale: Documenting observable, measurable
physical findings (such as non-blanchable erythema over a bony
prominence) falls under the assessment phase as objective data,
which clinical guidelines classify clinically as a Stage 1 pressure
injury. Diagnosing, planning, and evaluating occur in
subsequent steps.
Question 2: Medication Administration Safety (The Rights
of Medication Administration)
,Before administering a scheduled dose of digoxin to a client, the
student nurse checks the medication label against the medication
administration record (MAR), verifies the client's identity using
two identifiers, and checks the apical pulse rate. Which
fundamental safety practice is being explicitly demonstrated?
A. The three checks and rights of medication administration
B. Independent double-check protocols for high-alert
narcotics exclusively
C. Passive clinical observation without verification
D. Post-administration adverse reaction evaluation
Correct Answer: A. The three checks and rights of
medication administration
Expert Rationale: Comparing the medication label to the
MAR, verifying patient identity, and checking parameters (like
apical pulse for digoxin) fulfill the core safety framework
known as the rights of medication administration and standard
medication safety checks.
Question 3: Wound Care & Tissue Healing (Primary vs.
Secondary Intention)
A nurse is caring for two clients: Client A underwent a clean
surgical incision closed with sutures, while Client B has a deep,
open pressure injury healing via granulation tissue formation
and wound contraction. How do these healing processes differ?
A. Client A is healing by secondary intention, and Client B by
primary intention.
, B. Client A is healing by primary intention (clean edges
approximated), while Client B is healing by secondary
intention (open wound filling from the bottom up).
C. Both clients are undergoing identical epithelialization
rates.
D. Client B requires immediate surgical suture closure.
Correct Answer: B. Client A is healing by primary intention
(clean edges approximated), while Client B is healing by
secondary intention (open wound filling from the bottom
up).
Expert Rationale: Primary intention occurs when wound
margins are well-approximated (surgical incisions), resulting in
minimal scar formation. Secondary intention involves a gap
where granulation tissue must fill the wound from the base
upward, carrying a higher risk of infection and larger scar tissue.
Question 4: Vital Signs Assessment (Orthostatic
Hypotension Protocol)
A nurse suspects that an older adult client is experiencing
orthostatic hypotension after starting a new antihypertensive
medication. Which accurate sequence should the nurse follow
when assessing for orthostatic changes?
A. Measure blood pressure and pulse only while the client is
running on a treadmill.
Questions and Answers with Rationale
2026/2027 Update
Question 1: Clinical Judgement & The Nursing Process
(Assessment Phase)
A newly admitted client is assessed by a nurse who notes a
reddened, non-blanchable area over the sacrum. How should the
nurse correctly document and classify this initial finding within
the nursing process framework?
A. As a nursing diagnosis of Impaired Skin Integrity
B. As objective subjective data reflecting a Stage 1 Pressure
Injury
C. As an evaluation outcome measurement
D. As a dependent medical intervention order
Correct Answer: B. As objective subjective data reflecting a
Stage 1 Pressure Injury
Expert Rationale: Documenting observable, measurable
physical findings (such as non-blanchable erythema over a bony
prominence) falls under the assessment phase as objective data,
which clinical guidelines classify clinically as a Stage 1 pressure
injury. Diagnosing, planning, and evaluating occur in
subsequent steps.
Question 2: Medication Administration Safety (The Rights
of Medication Administration)
,Before administering a scheduled dose of digoxin to a client, the
student nurse checks the medication label against the medication
administration record (MAR), verifies the client's identity using
two identifiers, and checks the apical pulse rate. Which
fundamental safety practice is being explicitly demonstrated?
A. The three checks and rights of medication administration
B. Independent double-check protocols for high-alert
narcotics exclusively
C. Passive clinical observation without verification
D. Post-administration adverse reaction evaluation
Correct Answer: A. The three checks and rights of
medication administration
Expert Rationale: Comparing the medication label to the
MAR, verifying patient identity, and checking parameters (like
apical pulse for digoxin) fulfill the core safety framework
known as the rights of medication administration and standard
medication safety checks.
Question 3: Wound Care & Tissue Healing (Primary vs.
Secondary Intention)
A nurse is caring for two clients: Client A underwent a clean
surgical incision closed with sutures, while Client B has a deep,
open pressure injury healing via granulation tissue formation
and wound contraction. How do these healing processes differ?
A. Client A is healing by secondary intention, and Client B by
primary intention.
, B. Client A is healing by primary intention (clean edges
approximated), while Client B is healing by secondary
intention (open wound filling from the bottom up).
C. Both clients are undergoing identical epithelialization
rates.
D. Client B requires immediate surgical suture closure.
Correct Answer: B. Client A is healing by primary intention
(clean edges approximated), while Client B is healing by
secondary intention (open wound filling from the bottom
up).
Expert Rationale: Primary intention occurs when wound
margins are well-approximated (surgical incisions), resulting in
minimal scar formation. Secondary intention involves a gap
where granulation tissue must fill the wound from the base
upward, carrying a higher risk of infection and larger scar tissue.
Question 4: Vital Signs Assessment (Orthostatic
Hypotension Protocol)
A nurse suspects that an older adult client is experiencing
orthostatic hypotension after starting a new antihypertensive
medication. Which accurate sequence should the nurse follow
when assessing for orthostatic changes?
A. Measure blood pressure and pulse only while the client is
running on a treadmill.
