NU 136 / NU136 — Exam 1 (V1) verified with correct answers plus
rationales 2026/2027 version
Question 1
A nurse is beginning an assessment of a newly admitted client. Which action should the nurse
perform first?
A. Review the client's discharge instructions
B. Assess airway, breathing, circulation, and immediate safety
C. Ask about the client's favorite foods
D. Complete the room inventory
Answer: B. Assess airway, breathing, circulation, and immediate safety
Rationale: Initial nursing priorities focus on life-threatening problems using ABCs and safety.
Routine information can be obtained after immediate threats are addressed.
Question 2
Which finding requires the nurse's immediate attention?
A. Temperature of 37.2°C (99.0°F)
B. Oxygen saturation of 83% with respiratory distress
C. Pain rated 3/10
D. Mild fatigue
Answer: B. Oxygen saturation of 83% with respiratory distress
Rationale: Severe hypoxemia combined with respiratory distress indicates impaired oxygenation
and requires immediate intervention.
Question 3
Which position is generally most appropriate for a client experiencing shortness of breath?
A. High-Fowler's
B. Supine
C. Trendelenburg
D. Prone
,Answer: A. High-Fowler's
Rationale: Elevating the head of the bed improves lung expansion and can decrease the work of
breathing.
Question 4
A nurse is assessing a client's pain. Which question is most appropriate?
A. “You aren't really in pain, are you?”
B. “Describe where the pain is and what it feels like.”
C. “Why didn't you report this earlier?”
D. “Does your family think you're in pain?”
Answer: B. “Describe where the pain is and what it feels like.”
Rationale: Open-ended questions allow the client to describe the location and quality of pain.
Pain assessment should include intensity, location, quality, timing, and aggravating or relieving
factors.
Question 5
Which statement about pain assessment is correct?
A. Pain can be measured only by vital signs.
B. The client's self-report is an important source of pain assessment when the client can
communicate.
C. Clients who are smiling cannot have severe pain.
D. Nurses should determine pain severity without asking the client.
Answer: B.
Rationale: Pain is subjective. When clients can communicate, their report is the primary source
of information about pain.
Question 6
A nurse is assessing a client who has a fever. Which finding requires the most concern?
,A. Mild fatigue
B. Hypotension, tachycardia, and altered mental status
C. Slightly decreased appetite
D. Warm skin
Answer: B. Hypotension, tachycardia, and altered mental status
Rationale: These findings may indicate systemic infection with impaired perfusion and possible
sepsis, requiring urgent assessment.
Question 7
Which intervention is appropriate for a client with fever when not contraindicated?
A. Encourage appropriate fluid intake.
B. Restrict all fluids.
C. Keep the client under heavy blankets.
D. Avoid reassessing temperature.
Answer: A. Encourage appropriate fluid intake.
Rationale: Fever can increase fluid losses. Hydration helps maintain fluid balance when there
are no contraindications.
Question 8
Which finding is most consistent with dehydration?
A. Peripheral edema
B. Dry mucous membranes and concentrated urine
C. Crackles in both lungs
D. Rapid weight gain
Answer: B. Dry mucous membranes and concentrated urine
Rationale: Dehydration can cause thirst, dry mucous membranes, concentrated urine, decreased
urine output, weakness, and tachycardia.
Question 9
, A nurse is measuring intake and output. Which should be recorded as output?
A. 240 mL oral water
B. 500 mL IV fluid
C. 400 mL urine
D. 250 mL enteral feeding
Answer: C. 400 mL urine
Rationale: Urine is measurable fluid output. Oral, IV, and enteral fluids are forms of intake.
Question 10
A client has a urinary catheter. Which action helps reduce the risk of infection?
A. Keep the drainage bag below bladder level.
B. Disconnect the drainage system frequently.
C. Place the drainage bag on the bed.
D. Allow the tubing to become kinked.
Answer: A. Keep the drainage bag below bladder level.
Rationale: Keeping the drainage bag below bladder level promotes drainage and reduces the risk
of backflow into the bladder.
Question 11
A client reports burning and increased frequency when urinating. Which condition should the
nurse suspect?
A. Urinary tract infection
B. Hypoglycemia
C. Heart failure
D. Pneumothorax
Answer: A. Urinary tract infection
Rationale: Dysuria and urinary frequency are common manifestations of a UTI.
Question 12
rationales 2026/2027 version
Question 1
A nurse is beginning an assessment of a newly admitted client. Which action should the nurse
perform first?
A. Review the client's discharge instructions
B. Assess airway, breathing, circulation, and immediate safety
C. Ask about the client's favorite foods
D. Complete the room inventory
Answer: B. Assess airway, breathing, circulation, and immediate safety
Rationale: Initial nursing priorities focus on life-threatening problems using ABCs and safety.
Routine information can be obtained after immediate threats are addressed.
Question 2
Which finding requires the nurse's immediate attention?
A. Temperature of 37.2°C (99.0°F)
B. Oxygen saturation of 83% with respiratory distress
C. Pain rated 3/10
D. Mild fatigue
Answer: B. Oxygen saturation of 83% with respiratory distress
Rationale: Severe hypoxemia combined with respiratory distress indicates impaired oxygenation
and requires immediate intervention.
Question 3
Which position is generally most appropriate for a client experiencing shortness of breath?
A. High-Fowler's
B. Supine
C. Trendelenburg
D. Prone
,Answer: A. High-Fowler's
Rationale: Elevating the head of the bed improves lung expansion and can decrease the work of
breathing.
Question 4
A nurse is assessing a client's pain. Which question is most appropriate?
A. “You aren't really in pain, are you?”
B. “Describe where the pain is and what it feels like.”
C. “Why didn't you report this earlier?”
D. “Does your family think you're in pain?”
Answer: B. “Describe where the pain is and what it feels like.”
Rationale: Open-ended questions allow the client to describe the location and quality of pain.
Pain assessment should include intensity, location, quality, timing, and aggravating or relieving
factors.
Question 5
Which statement about pain assessment is correct?
A. Pain can be measured only by vital signs.
B. The client's self-report is an important source of pain assessment when the client can
communicate.
C. Clients who are smiling cannot have severe pain.
D. Nurses should determine pain severity without asking the client.
Answer: B.
Rationale: Pain is subjective. When clients can communicate, their report is the primary source
of information about pain.
Question 6
A nurse is assessing a client who has a fever. Which finding requires the most concern?
,A. Mild fatigue
B. Hypotension, tachycardia, and altered mental status
C. Slightly decreased appetite
D. Warm skin
Answer: B. Hypotension, tachycardia, and altered mental status
Rationale: These findings may indicate systemic infection with impaired perfusion and possible
sepsis, requiring urgent assessment.
Question 7
Which intervention is appropriate for a client with fever when not contraindicated?
A. Encourage appropriate fluid intake.
B. Restrict all fluids.
C. Keep the client under heavy blankets.
D. Avoid reassessing temperature.
Answer: A. Encourage appropriate fluid intake.
Rationale: Fever can increase fluid losses. Hydration helps maintain fluid balance when there
are no contraindications.
Question 8
Which finding is most consistent with dehydration?
A. Peripheral edema
B. Dry mucous membranes and concentrated urine
C. Crackles in both lungs
D. Rapid weight gain
Answer: B. Dry mucous membranes and concentrated urine
Rationale: Dehydration can cause thirst, dry mucous membranes, concentrated urine, decreased
urine output, weakness, and tachycardia.
Question 9
, A nurse is measuring intake and output. Which should be recorded as output?
A. 240 mL oral water
B. 500 mL IV fluid
C. 400 mL urine
D. 250 mL enteral feeding
Answer: C. 400 mL urine
Rationale: Urine is measurable fluid output. Oral, IV, and enteral fluids are forms of intake.
Question 10
A client has a urinary catheter. Which action helps reduce the risk of infection?
A. Keep the drainage bag below bladder level.
B. Disconnect the drainage system frequently.
C. Place the drainage bag on the bed.
D. Allow the tubing to become kinked.
Answer: A. Keep the drainage bag below bladder level.
Rationale: Keeping the drainage bag below bladder level promotes drainage and reduces the risk
of backflow into the bladder.
Question 11
A client reports burning and increased frequency when urinating. Which condition should the
nurse suspect?
A. Urinary tract infection
B. Hypoglycemia
C. Heart failure
D. Pneumothorax
Answer: A. Urinary tract infection
Rationale: Dysuria and urinary frequency are common manifestations of a UTI.
Question 12
