Recent Exam 2026-2027 Actual Complete Real Exam
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A client has a wound on his left trochanter that is 4 inches in
diameter, with black tissue at the perimeter, and bone is
exposed. Which is the nurse's best action?
A) Document as a stage I pressure ulcer and apply a
transparent dressing.
B) Document as a stage II pressure ulcer and start wet-to-dry
gauze treatments. C) Document as a stage IV pressure ulcer
and prepare the client for débridement.
D) Document as a stage III pressure ulcer and start antibiotic
therapy. -
ANSWER-C
A stage IV ulcer is one in which skin loss is full thickness, with
extensive destruction, tissue necrosis, and/or damage to
muscle, bone, or supporting structures. Eschar may be
present. When the bone of the trochanter area is visible, tissue
loss includes muscle loss. A potential intervention consists of
débridement of the necrotic tissue and a possible graft to
promote healing.
,After initial placement of NG tubes is confirmed, how often
must placement be
checked? SELECT ALL THAT
APPLY?
A) before medication administration
B) it is not necessary to recheck placement
C) every 4-8 hours during feeding
D) before intermittent feeding
E) according to facility policy - ANSWER-A,C,E
The nurse is preparing to administer tube feedings through a
client's new Salem sump nasogastric tube. The nurse is unable
to withdraw any fluid from the tube before starting the feeding.
Which is the priority action of the nurse?
A) Start the tube feeding as ordered and check the residual in
30 minutes.
B) Inject air into the nasogastric tube while auscultating the
client's epigastric area.
C) Lower the head of the client's bed and attempt to aspirate
fluid again.
D) Obtain orders for a chest x-ray to confirm placement before
starting the feeding. - ANSWER-D
The nurse must verify tube placement before beginning any
tube feeding or administering any medications through a tube.
The most accurate way to determine placement is via chest x-
,ray. The nurse could cause the client to aspirate if she or he
started the feeding then checked later for placement.
Insufflation does not provide accurate results and should not
be used to verify tube placement. The nurse must keep the
client's head elevated at least 30 degrees.
A client has a urinary tract infection. Which assessment by
the nurse is most
helpful?
A) Palpating and percussing the kidneys and bladder
B) Performing a bladder scan to assess post-void residual
C) Assessing medical history and current medical problems
D) Inquiring about recent travel to foreign countries - ANSWER-
C
Clients who are severely immune compromised or who have
diabetes mellitus are more prone to fungal urinary tract
infection. The nurse should assess for these factors. A physical
examination and a post-void residual may be needed, but not
until further information is obtained. Travel to foreign countries
probably would not be as important, because even if exposed,
the client needs some degree of immune compromise to
develop a fungal urinary tract infection.
When a diabetic patient asks about maintaining adequate blood
glucose levels,
which of the following statements by the nurse relates
most directly to the
, necessity of maintaining blood glucose levels no lower than
about 74 mg/dl?
A) "Without a minimum level of glucose circulating in the
blood, erythrocytes cannot produce ATP."
B) "The presence of glucose in the blood counteracts the
formation of lactic acid and prevents acidosis."
C) "The central nervous system cannot store glucose and
needs a continuous supply of glucose for fuel."
D) "Glucose is the only type of fuel used by body cells to
produce the energy needed for physiologic activity." -
ANSWER-C
The brain cannot synthesize or store significant amounts of
glucose; thus a
continuous supply from the body's circulation is needed
to meet the fuel
demands of the central nervous
system.
The nurse is caring for an overweight client who gained 10
pounds during the previous 2 weeks. The client states that she
is hungry all the time and doesn't understand why. Which
assessment finding could explain the client's weight gain and
hunger?
A) The client's glycosylated hemoglobin level is 6%.
B) The client started taking dexamethasone (Decadron) daily.
C) The client started taking naproxen sodium (Naprosyn) daily.