, NU 136: Fundamentals of Nursing Exam 4
Questions and Answers with Rationale
2026/2027 Update
Question 1: Fundamentals of Nursing (Gastrointestinal Care
& Ostomy Management)
A nurse is assessing a newly created colostomy on a
postoperative client. Which clinical finding should the nurse
report immediately to the primary healthcare provider?
A. A pink and moist stoma protruding slightly above the
abdominal wall.
B. Mild edema of the stoma during the first 24 to 48 hours
postoperatively.
C. A dusky blue or purple stoma with dry, cold mucosal
tissue.
D. A small amount of serosanguineous drainage on the
faceplate dressing.
Correct Answer: C. A dusky blue or purple stoma with dry,
cold mucosal tissue.
Expert Rationale: A healthy stoma should appear pink-to-red,
moist, and well-vascularized. A dusky, purple, black, or dry
stoma indicates compromised blood supply (ischemia or
necrosis) and requires immediate surgical notification. Mild
postoperative edema and small amounts of serosanguineous
ooze are normal early findings.
Question 2: Fundamentals of Nursing (Urinary Elimination
& Catheterization)
,A nurse is preparing to insert an indwelling urinary catheter for
an adult female client. After establishing a sterile field and
opening supplies, what is the correct initial step for cleansing the
perineal area?
A. Cleanse straight down the center directly over the
urinary meatus first.
B. Cleanse from front to back, wiping the far labium majus,
then the near labium majus, and finally directly over the
center meatus using a fresh swab each time.
C. Cleanse from the anus toward the clitoris to remove
fecal contaminants.
D. Wash the entire perineum vigorously with a single dry
gauze pad.
Correct Answer: B. Cleanse from front to back, wiping the
far labium majus, then the near labium majus, and finally
directly over the center meatus using a fresh swab each time.
Expert Rationale: Aseptic perineal cleansing for female
catheterization must always move from front to back (clitoris
toward anus) using a clean antiseptic swab for each stroke to
prevent introducing microorganisms from the perianal region
into the sterile urinary tract.
Question 3: Fundamentals of Nursing (Sensory Perception &
Sensory Deprivation)
An older adult client admitted to a private room for strict
isolation exhibits lethargy, confusion, hallucinations, and
drowsiness. The nurse identifies these symptoms as indicative of
which sensory alteration?
, A. Sensory overload
B. Sensory deprivation
C. Normal age-related cognitive recovery
D. Acute hyperactive delirium caused by infection
Correct Answer: B. Sensory deprivation
Expert Rationale: Sensory deprivation results from insufficient
or monotonous sensory input, often caused by isolation, private
rooms, impaired hearing/vision, or restricted mobility.
Manifestations include boredom, anxiety, depression,
hallucinations, and confusion. Interventions include increasing
meaningful stimuli, socialization, and orientation cues.
Question 4: Fundamentals of Nursing (Rest, Sleep, and
Circadian Rhythms)
A hospitalized adult client complains of being repeatedly
awakened throughout the night, leading to fatigue, irritability,
and delayed healing. Which nursing intervention best supports
restorative sleep hygiene?
A. Keep overhead fluorescent exam lights fully illuminated
24 hours a day.
B. Cluster nursing care activities to provide uninhibited
periods of uninterrupted sleep, dim lights at night, and
minimize ambient noise.
C. Administer heavy central nervous system stimulants at
bedtime.
D. Wake the client every 45 minutes to assess subjective
alertness.
Questions and Answers with Rationale
2026/2027 Update
Question 1: Fundamentals of Nursing (Gastrointestinal Care
& Ostomy Management)
A nurse is assessing a newly created colostomy on a
postoperative client. Which clinical finding should the nurse
report immediately to the primary healthcare provider?
A. A pink and moist stoma protruding slightly above the
abdominal wall.
B. Mild edema of the stoma during the first 24 to 48 hours
postoperatively.
C. A dusky blue or purple stoma with dry, cold mucosal
tissue.
D. A small amount of serosanguineous drainage on the
faceplate dressing.
Correct Answer: C. A dusky blue or purple stoma with dry,
cold mucosal tissue.
Expert Rationale: A healthy stoma should appear pink-to-red,
moist, and well-vascularized. A dusky, purple, black, or dry
stoma indicates compromised blood supply (ischemia or
necrosis) and requires immediate surgical notification. Mild
postoperative edema and small amounts of serosanguineous
ooze are normal early findings.
Question 2: Fundamentals of Nursing (Urinary Elimination
& Catheterization)
,A nurse is preparing to insert an indwelling urinary catheter for
an adult female client. After establishing a sterile field and
opening supplies, what is the correct initial step for cleansing the
perineal area?
A. Cleanse straight down the center directly over the
urinary meatus first.
B. Cleanse from front to back, wiping the far labium majus,
then the near labium majus, and finally directly over the
center meatus using a fresh swab each time.
C. Cleanse from the anus toward the clitoris to remove
fecal contaminants.
D. Wash the entire perineum vigorously with a single dry
gauze pad.
Correct Answer: B. Cleanse from front to back, wiping the
far labium majus, then the near labium majus, and finally
directly over the center meatus using a fresh swab each time.
Expert Rationale: Aseptic perineal cleansing for female
catheterization must always move from front to back (clitoris
toward anus) using a clean antiseptic swab for each stroke to
prevent introducing microorganisms from the perianal region
into the sterile urinary tract.
Question 3: Fundamentals of Nursing (Sensory Perception &
Sensory Deprivation)
An older adult client admitted to a private room for strict
isolation exhibits lethargy, confusion, hallucinations, and
drowsiness. The nurse identifies these symptoms as indicative of
which sensory alteration?
, A. Sensory overload
B. Sensory deprivation
C. Normal age-related cognitive recovery
D. Acute hyperactive delirium caused by infection
Correct Answer: B. Sensory deprivation
Expert Rationale: Sensory deprivation results from insufficient
or monotonous sensory input, often caused by isolation, private
rooms, impaired hearing/vision, or restricted mobility.
Manifestations include boredom, anxiety, depression,
hallucinations, and confusion. Interventions include increasing
meaningful stimuli, socialization, and orientation cues.
Question 4: Fundamentals of Nursing (Rest, Sleep, and
Circadian Rhythms)
A hospitalized adult client complains of being repeatedly
awakened throughout the night, leading to fatigue, irritability,
and delayed healing. Which nursing intervention best supports
restorative sleep hygiene?
A. Keep overhead fluorescent exam lights fully illuminated
24 hours a day.
B. Cluster nursing care activities to provide uninhibited
periods of uninterrupted sleep, dim lights at night, and
minimize ambient noise.
C. Administer heavy central nervous system stimulants at
bedtime.
D. Wake the client every 45 minutes to assess subjective
alertness.
