ACTUAL EXAM TEST BANK 200
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) |ALREADY GRADED
2026/2027 Frequently Most Tested Questions and 100% Accurate From
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A nurse is assessing a client at risk for impaired skin integrity. Which factors increase this
risk?
a. Impaired mobility, poor nutrition, dehydration, and tissue trauma
b. Adequate hydration and balanced nutrition
c. Frequent repositioning and moisturizing
d. High protein intake and regular exercise
✔️ Correct Answer: a. Impaired mobility, poor nutrition, dehydration, and tissue trauma
Rationale:
Impaired tissue integrity is commonly caused by reduced perfusion, inadequate nutrition,
immobility, moisture imbalance, and exposure to irritants or trauma. These factors
compromise skin structure and healing ability. Adequate hydration (Option B) protects
skin integrity. Frequent repositioning (Option C) prevents breakdown. Balanced nutrition
(Option D) supports tissue repair.
A client presents with leg pain during walking that resolves with rest, shiny hairless skin,
and diminished pedal pulses. What is the most likely condition?
a. Peripheral artery disease (PAD)
b. Venous insufficiency
,c. Deep vein thrombosis (DVT)
d. Neuropathy
✔️ Correct Answer: a. Peripheral artery disease (PAD)
Rationale:
PAD is caused by atherosclerosis leading to decreased arterial blood flow. Classic signs
include intermittent claudication, hair loss, shiny skin, weak pulses, and pallor with
elevation. Venous insufficiency (Option B) causes edema and weeping wounds. DVT
(Option C) causes acute swelling and pain. Neuropathy (Option D) does not affect pulses.
A client with peripheral artery disease asks how to manage symptoms. Which instruction
is most appropriate?
a. Keep legs in a dependent position
b. Elevate legs above heart level
c. Apply compression stockings
d. Limit physical activity
✔️ Correct Answer: a. Keep legs in a dependent position
Rationale:
Keeping the legs dependent promotes arterial blood flow in PAD. Elevation and
compression can further reduce perfusion and should be avoided. Elevating legs (Option
B) reduces arterial flow. Compression stockings (Option C) are contraindicated in PAD.
Limiting movement (Option D) is not recommended; exercise improves circulation.
A wound is noted on the tip of a client's toe. It appears round, "punched out," with
minimal drainage and black eschar. What type of ulcer is this?
a. Arterial ulcer
b. Venous ulcer
c. Pressure injury
d. Diabetic ulcer
✔️ Correct Answer: a. Arterial ulcer
Rationale:
Arterial ulcers occur due to poor perfusion and are typically found on toes or lateral
,malleolus. They appear well-defined, deep, and may have black eschar due to tissue
necrosis. Venous ulcers (Option B) are irregular with heavy drainage. Pressure injuries
(Option C) occur over bony prominences. Diabetic ulcers (Option D) are often on the
plantar surface.
A client presents with lower leg edema, brown discoloration, and a weeping wound near
the medial malleolus. What is the most likely diagnosis?
a. Chronic venous insufficiency
b. Peripheral artery disease
c. Cellulitis
d. Deep vein thrombosis
✔️ Correct Answer: a. Chronic venous insufficiency
Rationale:
Venous insufficiency results from valve failure, leading to blood pooling. Symptoms
include edema, hemosiderin staining, and irregular draining ulcers near the medial
malleolus. PAD (Option B) presents with dry, pale skin. Cellulitis (Option C) presents with
acute infection signs. DVT (Option D) presents with acute swelling without skin
discoloration pattern.
A client is at risk for pressure injuries. Which intervention is most effective for
prevention?
a. Reposition the client every 2 hours
b. Limit movement and activity
c. Keep skin moist with lotion
d. Provide a low-protein diet
✔️ Correct Answer: a. Reposition the client every 2 hours
Rationale:
Frequent repositioning reduces prolonged pressure on tissues, improving circulation and
preventing ischemia that leads to pressure injuries. Limiting movement (Option B)
increases risk. Moist skin (Option C) increases breakdown risk. Low-protein diet (Option
D) impairs healing.
, A client has full-thickness skin loss with visible bone. What stage pressure injury is this?
a. Stage 4
b. Stage 1
c. Stage 2
d. Stage 3
✔️ Correct Answer: a. Stage 4
Rationale:
Stage 4 pressure injuries involve full-thickness tissue loss with exposed bone, tendon, or
muscle, indicating severe damage. Stage 1 (Option B) has intact skin only. Stage 2
(Option C) has partial thickness. Stage 3 (Option D) has no exposed bone.
A client with left-sided heart failure presents with shortness of breath and crackles. What
is the underlying cause?
a. Blood backing up into the pulmonary circulation
b. Systemic venous congestion
c. Kidney failure
d. Liver congestion
✔️ Correct Answer: a. Blood backing up into the pulmonary circulation
Rationale:
Left-sided heart failure causes blood to back up into the lungs, leading to pulmonary
edema, dyspnea, orthopnea, and crackles. Systemic venous congestion (Option B) is
right-sided failure. Kidney failure (Option C) is not the primary cause. Liver congestion
(Option D) is right-sided failure.
A client with diabetic ketoacidosis (DKA) has a blood glucose of 320 mg/dL. What is the
priority before administering insulin?
a. Check potassium level
b. Check sodium level
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) |ALREADY GRADED
2026/2027 Frequently Most Tested Questions and 100% Accurate From
Past papers | Graded A+ , Reviewed and Updated | 100% Guarantee
Pass | Latest Exam and Newest Version!!!
A nurse is assessing a client at risk for impaired skin integrity. Which factors increase this
risk?
a. Impaired mobility, poor nutrition, dehydration, and tissue trauma
b. Adequate hydration and balanced nutrition
c. Frequent repositioning and moisturizing
d. High protein intake and regular exercise
✔️ Correct Answer: a. Impaired mobility, poor nutrition, dehydration, and tissue trauma
Rationale:
Impaired tissue integrity is commonly caused by reduced perfusion, inadequate nutrition,
immobility, moisture imbalance, and exposure to irritants or trauma. These factors
compromise skin structure and healing ability. Adequate hydration (Option B) protects
skin integrity. Frequent repositioning (Option C) prevents breakdown. Balanced nutrition
(Option D) supports tissue repair.
A client presents with leg pain during walking that resolves with rest, shiny hairless skin,
and diminished pedal pulses. What is the most likely condition?
a. Peripheral artery disease (PAD)
b. Venous insufficiency
,c. Deep vein thrombosis (DVT)
d. Neuropathy
✔️ Correct Answer: a. Peripheral artery disease (PAD)
Rationale:
PAD is caused by atherosclerosis leading to decreased arterial blood flow. Classic signs
include intermittent claudication, hair loss, shiny skin, weak pulses, and pallor with
elevation. Venous insufficiency (Option B) causes edema and weeping wounds. DVT
(Option C) causes acute swelling and pain. Neuropathy (Option D) does not affect pulses.
A client with peripheral artery disease asks how to manage symptoms. Which instruction
is most appropriate?
a. Keep legs in a dependent position
b. Elevate legs above heart level
c. Apply compression stockings
d. Limit physical activity
✔️ Correct Answer: a. Keep legs in a dependent position
Rationale:
Keeping the legs dependent promotes arterial blood flow in PAD. Elevation and
compression can further reduce perfusion and should be avoided. Elevating legs (Option
B) reduces arterial flow. Compression stockings (Option C) are contraindicated in PAD.
Limiting movement (Option D) is not recommended; exercise improves circulation.
A wound is noted on the tip of a client's toe. It appears round, "punched out," with
minimal drainage and black eschar. What type of ulcer is this?
a. Arterial ulcer
b. Venous ulcer
c. Pressure injury
d. Diabetic ulcer
✔️ Correct Answer: a. Arterial ulcer
Rationale:
Arterial ulcers occur due to poor perfusion and are typically found on toes or lateral
,malleolus. They appear well-defined, deep, and may have black eschar due to tissue
necrosis. Venous ulcers (Option B) are irregular with heavy drainage. Pressure injuries
(Option C) occur over bony prominences. Diabetic ulcers (Option D) are often on the
plantar surface.
A client presents with lower leg edema, brown discoloration, and a weeping wound near
the medial malleolus. What is the most likely diagnosis?
a. Chronic venous insufficiency
b. Peripheral artery disease
c. Cellulitis
d. Deep vein thrombosis
✔️ Correct Answer: a. Chronic venous insufficiency
Rationale:
Venous insufficiency results from valve failure, leading to blood pooling. Symptoms
include edema, hemosiderin staining, and irregular draining ulcers near the medial
malleolus. PAD (Option B) presents with dry, pale skin. Cellulitis (Option C) presents with
acute infection signs. DVT (Option D) presents with acute swelling without skin
discoloration pattern.
A client is at risk for pressure injuries. Which intervention is most effective for
prevention?
a. Reposition the client every 2 hours
b. Limit movement and activity
c. Keep skin moist with lotion
d. Provide a low-protein diet
✔️ Correct Answer: a. Reposition the client every 2 hours
Rationale:
Frequent repositioning reduces prolonged pressure on tissues, improving circulation and
preventing ischemia that leads to pressure injuries. Limiting movement (Option B)
increases risk. Moist skin (Option C) increases breakdown risk. Low-protein diet (Option
D) impairs healing.
, A client has full-thickness skin loss with visible bone. What stage pressure injury is this?
a. Stage 4
b. Stage 1
c. Stage 2
d. Stage 3
✔️ Correct Answer: a. Stage 4
Rationale:
Stage 4 pressure injuries involve full-thickness tissue loss with exposed bone, tendon, or
muscle, indicating severe damage. Stage 1 (Option B) has intact skin only. Stage 2
(Option C) has partial thickness. Stage 3 (Option D) has no exposed bone.
A client with left-sided heart failure presents with shortness of breath and crackles. What
is the underlying cause?
a. Blood backing up into the pulmonary circulation
b. Systemic venous congestion
c. Kidney failure
d. Liver congestion
✔️ Correct Answer: a. Blood backing up into the pulmonary circulation
Rationale:
Left-sided heart failure causes blood to back up into the lungs, leading to pulmonary
edema, dyspnea, orthopnea, and crackles. Systemic venous congestion (Option B) is
right-sided failure. Kidney failure (Option C) is not the primary cause. Liver congestion
(Option D) is right-sided failure.
A client with diabetic ketoacidosis (DKA) has a blood glucose of 320 mg/dL. What is the
priority before administering insulin?
a. Check potassium level
b. Check sodium level
