PN 2002 Final Review Latest 2026 Actual Exam Complete Real
Exam Questions and Correct Verified Answers
Already Graded A+ | Questions
1. A nurse is preparing to administer a subcutaneous injection of heparin. Which
action is correct for this procedure?
A. Massage the site after injection
B. Use the Z-track method
C. Do not aspirate before injecting
D. Inject into the deltoid muscle
Answer: C
Rationale: When administering subcutaneous heparin, the nurse should not aspirate
before injecting to prevent tissue damage. The site should not be massaged after injection
as this can cause bruising. The Z-track method is used for intramuscular injections, not
subcutaneous. Heparin is given subcutaneously, not intramuscularly.
2. A patient is receiving IV fluids through a peripheral line. The nurse notes that
the IV site is red, warm, and tender. What is the nurse's priority action?
A. Apply a warm compress
B. Slow the infusion rate
C. Discontinue the IV and restart at a different site
D. Document the findings
Answer: C
Rationale: Redness, warmth, and tenderness at the IV site indicate phlebitis (inflammation
of the vein). The IV should be discontinued immediately and restarted at a different site.
,Applying a warm compress may be ordered after the IV is removed, but it is not the
priority. Slowing the rate does not address the inflammation.
3. A patient with a history of falls is being discharged home. Which environmental
modification is most important for fall prevention?
A. Remove throw rugs
B. Install carpet throughout the home
C. Close curtains to reduce glare
D. Keep furniture in the same arrangement
Answer: A
Rationale: Throw rugs are a significant fall hazard, especially for older adults or those with
mobility issues. They should be removed or secured with non-slip backing. Carpeting may
also pose a fall risk if uneven. Closing curtains can create dim lighting, increasing fall risk.
Keeping furniture in the same arrangement may be helpful for familiarization but does
not directly prevent falls.
4. A nurse is assessing a patient's wound and notes undermining at the wound
edges. What does this finding indicate?
A. The wound is healing normally
B. Tissue destruction extends under the skin
C. The wound is infected
D. The wound requires debridement
Answer: B
Rationale: Undermining occurs when tissue destruction extends under the wound edges,
creating a "pocket" beneath the intact skin. It indicates pressure injury progression or
tunneling. Normal healing does not involve undermining. Undermining may be present in
infected wounds but is not a direct sign of infection itself. Debridement may be needed but
is not indicated solely by undermining.
,5. A patient is on a clear liquid diet. Which item can the patient have?
A. Cream of chicken soup
B. Orange juice with pulp
C. Clear broth
D. Milkshake
Answer: C
Rationale: Clear liquids include broth, clear juices (apple, cranberry, grape), gelatin, and
popsicles. Cream soups, orange juice with pulp, and milkshakes are not clear liquids and
would not be allowed on a clear liquid diet.
6. A nurse is preparing to administer an enteral feeding through a gastrostomy
tube. Which action should the nurse take first?
A. Flush the tube with 30 mL of water
B. Verify tube placement by aspirating gastric contents
C. Check the residual volume
D. Position the patient in a supine position
Answer: B
Rationale: Verifying tube placement by aspirating gastric contents and checking pH is the
priority action to prevent aspiration and ensure the tube is correctly positioned in the
stomach before initiating the feeding. Flushing and checking residuals come after
placement verification. The patient should be positioned in semi-Fowler's or Fowler's
position, not supine, to reduce aspiration risk.
7. A patient with a urinary catheter has a urine output of 400 mL over 12 hours.
What is the nurse's priority action?
A. Document the output as normal
B. Increase the patient's oral fluid intake
C. Notify the healthcare provider
D. Irrigate the catheter with sterile saline
, Answer: C
Rationale: Urine output should be at least 30 mL/hour, or 360 mL over 12 hours. An
output of 400 mL over 12 hours is only 33 mL/hour, which is slightly below normal but not
immediately critical. However, this is borderline and should be monitored closely. Actually,
400 mL over 12 hours is approximately 33 mL/hour, which is within normal range (≥30
mL/hour). The correct answer is A - document as normal. (Let me recalculate: 400 mL ÷ 12
hours = 33.3 mL/hour, which is above the minimum of 30 mL/hour. So the output is
actually normal.)
Answer: A
Rationale: Urine output of 400 mL over 12 hours equals approximately 33 mL/hour, which
is within the normal range of at least 30 mL/hour. The nurse should document the output
as normal. However, if the output continues to decrease, further assessment and
notification may be needed.
8. The nurse is providing education to a patient with a new colostomy. Which
statement by the patient indicates understanding?
A. "I will change my pouch daily"
B. "I will eat foods that help form solid stool"
C. "I will avoid all foods with fiber"
D. "I will irrigate my colostomy every day"
Answer: B
Rationale: Patients with a colostomy should eat foods that help form solid stool, such as
applesauce, bananas, and rice. Pouches should be changed every 3-7 days or as needed,
not daily. Fiber should not be completely avoided but may need to be adjusted. Irrigation
is not necessary for all colostomies and is typically done only for specific types.
9. A patient is receiving a blood transfusion. The nurse notes that the patient has
developed a fever and chills. What is the nurse's priority action?
A. Slow the transfusion rate
B. Stop the transfusion immediately
Exam Questions and Correct Verified Answers
Already Graded A+ | Questions
1. A nurse is preparing to administer a subcutaneous injection of heparin. Which
action is correct for this procedure?
A. Massage the site after injection
B. Use the Z-track method
C. Do not aspirate before injecting
D. Inject into the deltoid muscle
Answer: C
Rationale: When administering subcutaneous heparin, the nurse should not aspirate
before injecting to prevent tissue damage. The site should not be massaged after injection
as this can cause bruising. The Z-track method is used for intramuscular injections, not
subcutaneous. Heparin is given subcutaneously, not intramuscularly.
2. A patient is receiving IV fluids through a peripheral line. The nurse notes that
the IV site is red, warm, and tender. What is the nurse's priority action?
A. Apply a warm compress
B. Slow the infusion rate
C. Discontinue the IV and restart at a different site
D. Document the findings
Answer: C
Rationale: Redness, warmth, and tenderness at the IV site indicate phlebitis (inflammation
of the vein). The IV should be discontinued immediately and restarted at a different site.
,Applying a warm compress may be ordered after the IV is removed, but it is not the
priority. Slowing the rate does not address the inflammation.
3. A patient with a history of falls is being discharged home. Which environmental
modification is most important for fall prevention?
A. Remove throw rugs
B. Install carpet throughout the home
C. Close curtains to reduce glare
D. Keep furniture in the same arrangement
Answer: A
Rationale: Throw rugs are a significant fall hazard, especially for older adults or those with
mobility issues. They should be removed or secured with non-slip backing. Carpeting may
also pose a fall risk if uneven. Closing curtains can create dim lighting, increasing fall risk.
Keeping furniture in the same arrangement may be helpful for familiarization but does
not directly prevent falls.
4. A nurse is assessing a patient's wound and notes undermining at the wound
edges. What does this finding indicate?
A. The wound is healing normally
B. Tissue destruction extends under the skin
C. The wound is infected
D. The wound requires debridement
Answer: B
Rationale: Undermining occurs when tissue destruction extends under the wound edges,
creating a "pocket" beneath the intact skin. It indicates pressure injury progression or
tunneling. Normal healing does not involve undermining. Undermining may be present in
infected wounds but is not a direct sign of infection itself. Debridement may be needed but
is not indicated solely by undermining.
,5. A patient is on a clear liquid diet. Which item can the patient have?
A. Cream of chicken soup
B. Orange juice with pulp
C. Clear broth
D. Milkshake
Answer: C
Rationale: Clear liquids include broth, clear juices (apple, cranberry, grape), gelatin, and
popsicles. Cream soups, orange juice with pulp, and milkshakes are not clear liquids and
would not be allowed on a clear liquid diet.
6. A nurse is preparing to administer an enteral feeding through a gastrostomy
tube. Which action should the nurse take first?
A. Flush the tube with 30 mL of water
B. Verify tube placement by aspirating gastric contents
C. Check the residual volume
D. Position the patient in a supine position
Answer: B
Rationale: Verifying tube placement by aspirating gastric contents and checking pH is the
priority action to prevent aspiration and ensure the tube is correctly positioned in the
stomach before initiating the feeding. Flushing and checking residuals come after
placement verification. The patient should be positioned in semi-Fowler's or Fowler's
position, not supine, to reduce aspiration risk.
7. A patient with a urinary catheter has a urine output of 400 mL over 12 hours.
What is the nurse's priority action?
A. Document the output as normal
B. Increase the patient's oral fluid intake
C. Notify the healthcare provider
D. Irrigate the catheter with sterile saline
, Answer: C
Rationale: Urine output should be at least 30 mL/hour, or 360 mL over 12 hours. An
output of 400 mL over 12 hours is only 33 mL/hour, which is slightly below normal but not
immediately critical. However, this is borderline and should be monitored closely. Actually,
400 mL over 12 hours is approximately 33 mL/hour, which is within normal range (≥30
mL/hour). The correct answer is A - document as normal. (Let me recalculate: 400 mL ÷ 12
hours = 33.3 mL/hour, which is above the minimum of 30 mL/hour. So the output is
actually normal.)
Answer: A
Rationale: Urine output of 400 mL over 12 hours equals approximately 33 mL/hour, which
is within the normal range of at least 30 mL/hour. The nurse should document the output
as normal. However, if the output continues to decrease, further assessment and
notification may be needed.
8. The nurse is providing education to a patient with a new colostomy. Which
statement by the patient indicates understanding?
A. "I will change my pouch daily"
B. "I will eat foods that help form solid stool"
C. "I will avoid all foods with fiber"
D. "I will irrigate my colostomy every day"
Answer: B
Rationale: Patients with a colostomy should eat foods that help form solid stool, such as
applesauce, bananas, and rice. Pouches should be changed every 3-7 days or as needed,
not daily. Fiber should not be completely avoided but may need to be adjusted. Irrigation
is not necessary for all colostomies and is typically done only for specific types.
9. A patient is receiving a blood transfusion. The nurse notes that the patient has
developed a fever and chills. What is the nurse's priority action?
A. Slow the transfusion rate
B. Stop the transfusion immediately
