,NU 136: Fundamentals of Nursing – NCLEX
Questions and Answers with Rationales
2026/2027 Update
Question 1
A nurse is caring for an adult client who has a prescription for a
continuous intravenous infusion of 0.9% sodium chloride. The
nurse notices swelling, coolness, and pallor around the
intravenous insertion site, and the infusion has slowed down
significantly. Which complication has occurred?
A. Infiltration
B. Phlebitis
C. Thrombosis
D. Air embolism
Correct Answer: A. Infiltration
Expert Rationale: Infiltration occurs when intravenous fluid
accidentally enters the subcutaneous tissue surrounding the
venipuncture site due to catheter displacement or vessel wall
leakage. Signs include localized swelling, coolness, pallor, and
slowed infusion rates. The nurse must stop the infusion
immediately, remove the catheter, and elevate the limb.
Question 2
A nurse is auscultating the lungs of an adult client and hears
discontinuous, non-musical, popping sounds heard primarily
,during inspiration that do not clear with coughing. How should
the nurse document this finding?
A. Sibilant wheezes
B. Pleural friction rub
C. Fine or coarse crackles (rales)
D. Stridor
Correct Answer: C. Fine or coarse crackles (rales)
Expert Rationale: Crackles (rales) are discontinuous, popping
breath sounds heard most commonly during inspiration, caused
by air opening previously deflated small airways or fluid in
alveoli. Wheezes are continuous musical sounds, and stridor is a
harsh high-pitched upper airway sound.
Question 3
A nurse is admitting a client who is being placed on contact
precautions due to a multidrug-resistant organism (MDRO).
Which private room and barrier protection setup should the
nurse arrange?
A. A standard room with positive pressure airflow and no
masks required
B. A private room or cohort room, wearing a gown and gloves
for all interactions involving contact with the client or their
environment
, C. A private room requiring an N95 respirator mask and
negative pressure ventilation at all times
D. A semi-private room with unrestricted visitors and no
barrier gown requirements
Correct Answer: B. A private room or cohort room, wearing
a gown and gloves for all interactions involving contact with
the client or their environment
Expert Rationale: Contact precautions require a private room
(or cohorting clients with the same active infection) and the use
of personal protective equipment, specifically a gown and
gloves, upon entry to prevent direct or indirect transmission of
epidemiologically important pathogens.
Question 4
A nurse is performing a physical assessment on an adult client
and assesses skin turgor to evaluate hydration status. Where is
the best anatomical site to pinch the skin for a reliable turgor
assessment on an older adult client?
A. Over the dorsum of the hand
B. Over the sternum or the clavicle
C. Directly over the shinbone
D. Across the bridge of the nose
Correct Answer: B. Over the sternum or the clavicle
Questions and Answers with Rationales
2026/2027 Update
Question 1
A nurse is caring for an adult client who has a prescription for a
continuous intravenous infusion of 0.9% sodium chloride. The
nurse notices swelling, coolness, and pallor around the
intravenous insertion site, and the infusion has slowed down
significantly. Which complication has occurred?
A. Infiltration
B. Phlebitis
C. Thrombosis
D. Air embolism
Correct Answer: A. Infiltration
Expert Rationale: Infiltration occurs when intravenous fluid
accidentally enters the subcutaneous tissue surrounding the
venipuncture site due to catheter displacement or vessel wall
leakage. Signs include localized swelling, coolness, pallor, and
slowed infusion rates. The nurse must stop the infusion
immediately, remove the catheter, and elevate the limb.
Question 2
A nurse is auscultating the lungs of an adult client and hears
discontinuous, non-musical, popping sounds heard primarily
,during inspiration that do not clear with coughing. How should
the nurse document this finding?
A. Sibilant wheezes
B. Pleural friction rub
C. Fine or coarse crackles (rales)
D. Stridor
Correct Answer: C. Fine or coarse crackles (rales)
Expert Rationale: Crackles (rales) are discontinuous, popping
breath sounds heard most commonly during inspiration, caused
by air opening previously deflated small airways or fluid in
alveoli. Wheezes are continuous musical sounds, and stridor is a
harsh high-pitched upper airway sound.
Question 3
A nurse is admitting a client who is being placed on contact
precautions due to a multidrug-resistant organism (MDRO).
Which private room and barrier protection setup should the
nurse arrange?
A. A standard room with positive pressure airflow and no
masks required
B. A private room or cohort room, wearing a gown and gloves
for all interactions involving contact with the client or their
environment
, C. A private room requiring an N95 respirator mask and
negative pressure ventilation at all times
D. A semi-private room with unrestricted visitors and no
barrier gown requirements
Correct Answer: B. A private room or cohort room, wearing
a gown and gloves for all interactions involving contact with
the client or their environment
Expert Rationale: Contact precautions require a private room
(or cohorting clients with the same active infection) and the use
of personal protective equipment, specifically a gown and
gloves, upon entry to prevent direct or indirect transmission of
epidemiologically important pathogens.
Question 4
A nurse is performing a physical assessment on an adult client
and assesses skin turgor to evaluate hydration status. Where is
the best anatomical site to pinch the skin for a reliable turgor
assessment on an older adult client?
A. Over the dorsum of the hand
B. Over the sternum or the clavicle
C. Directly over the shinbone
D. Across the bridge of the nose
Correct Answer: B. Over the sternum or the clavicle
