NU-136 Exam Review Questions with Verified
Correct Answers
Normal adult urine output
30 mL/hr
A nurse is measuring a patients height. Which action is correct?
Measure from the sole of the foot to the crown of the head
Which item should the nurse include as intake when calculating i&o?
Iv fluids
Which sequence should the nurse use when performing a respiratory assessment ?
Both pupils constrict
A nurse shines a light into a patient's eye. What should happen to the pupil?
It constricts
Pt opens their eyes to pain only. What GCS score is this?
2
A pt is confused when answering questions. What verbal response score should the
nurse assign?
4
A pt obeys commands during a neurological assessment. What motor score should the
nurse assign ?
6
, The nurse assesses skin turgor. Which finding may indicate dehydration?
Skin remains elevated after being pinched
When assessing skin turgor in an older adult, which loco is best ?
Sternum
Which capillary refill finding is considered normal ?
Less than 3 secs
Inspect
Palpate
Percuss
Auscultate
Which breath sound is described as high pitched and caused by narrow airway ?
Wheeze
A pt has low pitched rattling sounds caused by mucus in the larger airways.which sound
is the nurse hearing?
Rhonchi
The nurse hears popping or bubbling sounds during auscultation. Which adventitious
sound is this ?
Crackles
A pt develops a harsh, high pitched sound associated with an upper airway obstruction.
What should the nurse do?
Recognize this as a medical emergency
Correct Answers
Normal adult urine output
30 mL/hr
A nurse is measuring a patients height. Which action is correct?
Measure from the sole of the foot to the crown of the head
Which item should the nurse include as intake when calculating i&o?
Iv fluids
Which sequence should the nurse use when performing a respiratory assessment ?
Both pupils constrict
A nurse shines a light into a patient's eye. What should happen to the pupil?
It constricts
Pt opens their eyes to pain only. What GCS score is this?
2
A pt is confused when answering questions. What verbal response score should the
nurse assign?
4
A pt obeys commands during a neurological assessment. What motor score should the
nurse assign ?
6
, The nurse assesses skin turgor. Which finding may indicate dehydration?
Skin remains elevated after being pinched
When assessing skin turgor in an older adult, which loco is best ?
Sternum
Which capillary refill finding is considered normal ?
Less than 3 secs
Inspect
Palpate
Percuss
Auscultate
Which breath sound is described as high pitched and caused by narrow airway ?
Wheeze
A pt has low pitched rattling sounds caused by mucus in the larger airways.which sound
is the nurse hearing?
Rhonchi
The nurse hears popping or bubbling sounds during auscultation. Which adventitious
sound is this ?
Crackles
A pt develops a harsh, high pitched sound associated with an upper airway obstruction.
What should the nurse do?
Recognize this as a medical emergency
