NU131 EXAM 2 Actual ExamIFT250-Final )
Exam with questions and well verified
answers actual!!!!! 2026
SECTION 1: NU131 (Nursing & Healthcare I) – Fundamentals & Clinical Safety
Q1. A nurse is preparing to administer medication to a patient with a known allergy to penicillin. The
prescribed medication is amoxicillin. What is the nurse’s priority action?
A) Administer the medication with an antihistamine premedication
B) Contact the prescriber to clarify the order
C) Document the allergy and proceed with administration
D) Ask the patient if they are sure about the allergy
✅ Correct Answer: B
Rationale
• A: Incorrect. Premedicating does not prevent severe allergic reactions and violates safety
protocols.
• B: Correct. Amoxicillin is a penicillin derivative; administering it could cause anaphylaxis. The
nurse must contact the prescriber for an alternative.
• C: Incorrect. Documentation does not mitigate the immediate risk of administering a
contraindicated drug.
• D: Incorrect. Patient confirmation is good practice but does not override the clinical duty to
verify safety before administration.
Q2. Which technique is most appropriate when measuring a patient’s blood pressure to ensure
accuracy?
A) Inflate the cuff 20 mmHg above the estimated systolic pressure
B) Place the cuff over the patient’s clothing to save time
,C) Deflate the cuff at a rate of 10 mmHg per second
D) Position the patient’s arm above heart level during measurement
✅ Correct Answer: A
Rationale
• A: Correct. Inflating 20–30 mmHg above estimated systolic ensures accurate auscultation of
Korotkoff sounds without overinflating.
• B: Incorrect. The cuff must be placed on bare skin; clothing causes falsely elevated readings.
• C: Incorrect. Recommended deflation rate is 2–3 mmHg/sec to avoid missing auscultatory gaps.
• D: Incorrect. The arm must be at heart level; positioning above causes falsely low readings.
Q3. A patient with a stage II pressure injury has serous drainage and intact surrounding skin. Which
dressing is most appropriate?
A) Dry gauze with tape
B) Transparent film dressing
C) Hydrocolloid dressing
D) Wet-to-dry gauze
✅ Correct Answer: C
Rationale
• A: Incorrect. Dry gauze adheres to the wound bed and causes trauma during removal.
• B: Incorrect. Transparent film is for minimal drainage and intact skin, not for absorbing exudate.
• C: Correct. Hydrocolloid dressings maintain a moist healing environment, absorb light-to-
moderate drainage, and protect surrounding skin.
• D: Incorrect. Wet-to-dry is outdated, causes mechanical debridement, and damages healthy
granulation tissue.
Q4. When teaching a patient about fall prevention, which statement indicates a need for further
instruction?
A) “I will keep my slippers on when walking to the bathroom.”
B) “I will use the call light if I feel dizzy.”
C) “I will keep my bedside table within arm’s reach.”
D) “I will wait for the nurse to help me stand up.”
✅ Correct Answer: A
Rationale
• A: Incorrect statement (needs correction). Loose slippers increase slip/fall risk; patients should
wear non-skid footwear.
• B: Correct statement. Using the call light for dizziness is safe and appropriate.
• C: Correct statement. Keeping essential items within reach prevents unsafe reaching or
standing.
, • D: Correct statement. Waiting for assistance reduces unassisted mobility risks.
Q5. Which action best demonstrates adherence to standard precautions during wound care?
A) Wearing sterile gloves only when handling surgical instruments
B) Donning clean gloves before removing old dressings and changing them after wound cleaning
C) Using the same gloves for perineal care and wound dressing changes
D) Skipping hand hygiene if gloves are worn
✅ Correct Answer: B
Rationale
• A: Incorrect. Clean gloves are standard for routine wound care unless a sterile procedure is
ordered.
• B: Correct. Changing gloves between dirty and clean tasks prevents cross-contamination and
follows CDC standard precautions.
• C: Incorrect. Perineal care is considered contaminated; gloves must be changed before clean
procedures.
• D: Incorrect. Hand hygiene is required before donning and after removing gloves, regardless of
glove use.
Q6. A nurse assesses a patient’s capillary refill and notes it takes 4 seconds. What is the most
appropriate interpretation?
A) Normal finding in an elderly patient
B) Indicates adequate peripheral perfusion
C) Suggests possible poor perfusion or dehydration
D) Requires immediate administration of vasopressors
✅ Correct Answer: C
Rationale
• A: Incorrect. Capillary refill >3 seconds is abnormal at any age and warrants further assessment.
• B: Incorrect. Normal refill is ≤3 seconds; 4 seconds indicates delayed perfusion.
• C: Correct. Prolonged refill suggests decreased peripheral circulation, often due to dehydration,
shock, or hypothermia.
• D: Incorrect. Vasopressors require a physician order and hemodynamic monitoring; initial steps
include fluid assessment and repositioning.
Q7. Which documentation method best follows the SOAP format for a post-op patient complaining of
pain?
A) S: “Patient states pain 7/10.” O: Grimacing, guarding incision. A: Acute pain related to surgical
trauma. P: Administered prescribed analgesic; re-evaluate in 30 min.
B) S: Administered morphine 2 mg IV. O: Pain decreased to 3/10. A: Effective pain management. P:
Continue monitoring.
C) S: Pain is present. O: Patient is uncomfortable. A: Needs medication. P: Gave Tylenol.
D) S: “I hurt.” O: Vital signs stable. A: Pain. P: Will reassess.
Exam with questions and well verified
answers actual!!!!! 2026
SECTION 1: NU131 (Nursing & Healthcare I) – Fundamentals & Clinical Safety
Q1. A nurse is preparing to administer medication to a patient with a known allergy to penicillin. The
prescribed medication is amoxicillin. What is the nurse’s priority action?
A) Administer the medication with an antihistamine premedication
B) Contact the prescriber to clarify the order
C) Document the allergy and proceed with administration
D) Ask the patient if they are sure about the allergy
✅ Correct Answer: B
Rationale
• A: Incorrect. Premedicating does not prevent severe allergic reactions and violates safety
protocols.
• B: Correct. Amoxicillin is a penicillin derivative; administering it could cause anaphylaxis. The
nurse must contact the prescriber for an alternative.
• C: Incorrect. Documentation does not mitigate the immediate risk of administering a
contraindicated drug.
• D: Incorrect. Patient confirmation is good practice but does not override the clinical duty to
verify safety before administration.
Q2. Which technique is most appropriate when measuring a patient’s blood pressure to ensure
accuracy?
A) Inflate the cuff 20 mmHg above the estimated systolic pressure
B) Place the cuff over the patient’s clothing to save time
,C) Deflate the cuff at a rate of 10 mmHg per second
D) Position the patient’s arm above heart level during measurement
✅ Correct Answer: A
Rationale
• A: Correct. Inflating 20–30 mmHg above estimated systolic ensures accurate auscultation of
Korotkoff sounds without overinflating.
• B: Incorrect. The cuff must be placed on bare skin; clothing causes falsely elevated readings.
• C: Incorrect. Recommended deflation rate is 2–3 mmHg/sec to avoid missing auscultatory gaps.
• D: Incorrect. The arm must be at heart level; positioning above causes falsely low readings.
Q3. A patient with a stage II pressure injury has serous drainage and intact surrounding skin. Which
dressing is most appropriate?
A) Dry gauze with tape
B) Transparent film dressing
C) Hydrocolloid dressing
D) Wet-to-dry gauze
✅ Correct Answer: C
Rationale
• A: Incorrect. Dry gauze adheres to the wound bed and causes trauma during removal.
• B: Incorrect. Transparent film is for minimal drainage and intact skin, not for absorbing exudate.
• C: Correct. Hydrocolloid dressings maintain a moist healing environment, absorb light-to-
moderate drainage, and protect surrounding skin.
• D: Incorrect. Wet-to-dry is outdated, causes mechanical debridement, and damages healthy
granulation tissue.
Q4. When teaching a patient about fall prevention, which statement indicates a need for further
instruction?
A) “I will keep my slippers on when walking to the bathroom.”
B) “I will use the call light if I feel dizzy.”
C) “I will keep my bedside table within arm’s reach.”
D) “I will wait for the nurse to help me stand up.”
✅ Correct Answer: A
Rationale
• A: Incorrect statement (needs correction). Loose slippers increase slip/fall risk; patients should
wear non-skid footwear.
• B: Correct statement. Using the call light for dizziness is safe and appropriate.
• C: Correct statement. Keeping essential items within reach prevents unsafe reaching or
standing.
, • D: Correct statement. Waiting for assistance reduces unassisted mobility risks.
Q5. Which action best demonstrates adherence to standard precautions during wound care?
A) Wearing sterile gloves only when handling surgical instruments
B) Donning clean gloves before removing old dressings and changing them after wound cleaning
C) Using the same gloves for perineal care and wound dressing changes
D) Skipping hand hygiene if gloves are worn
✅ Correct Answer: B
Rationale
• A: Incorrect. Clean gloves are standard for routine wound care unless a sterile procedure is
ordered.
• B: Correct. Changing gloves between dirty and clean tasks prevents cross-contamination and
follows CDC standard precautions.
• C: Incorrect. Perineal care is considered contaminated; gloves must be changed before clean
procedures.
• D: Incorrect. Hand hygiene is required before donning and after removing gloves, regardless of
glove use.
Q6. A nurse assesses a patient’s capillary refill and notes it takes 4 seconds. What is the most
appropriate interpretation?
A) Normal finding in an elderly patient
B) Indicates adequate peripheral perfusion
C) Suggests possible poor perfusion or dehydration
D) Requires immediate administration of vasopressors
✅ Correct Answer: C
Rationale
• A: Incorrect. Capillary refill >3 seconds is abnormal at any age and warrants further assessment.
• B: Incorrect. Normal refill is ≤3 seconds; 4 seconds indicates delayed perfusion.
• C: Correct. Prolonged refill suggests decreased peripheral circulation, often due to dehydration,
shock, or hypothermia.
• D: Incorrect. Vasopressors require a physician order and hemodynamic monitoring; initial steps
include fluid assessment and repositioning.
Q7. Which documentation method best follows the SOAP format for a post-op patient complaining of
pain?
A) S: “Patient states pain 7/10.” O: Grimacing, guarding incision. A: Acute pain related to surgical
trauma. P: Administered prescribed analgesic; re-evaluate in 30 min.
B) S: Administered morphine 2 mg IV. O: Pain decreased to 3/10. A: Effective pain management. P:
Continue monitoring.
C) S: Pain is present. O: Patient is uncomfortable. A: Needs medication. P: Gave Tylenol.
D) S: “I hurt.” O: Vital signs stable. A: Pain. P: Will reassess.
