TEST 2026 FULL QUESTIONS AND VERIFIED
SOLUTIONS
⩥ Pressure Ulcers and stages. Answer: stage I pressure ulcer- an area of
persistent redness with no break in skin integrity.
stage II pressure ulcer-partial-thickness wound with skin loss involving
the epidermis, dermis, or both; the ulcer is superficial and may present
as an abrasion, blister, or shallow crater
stage III pressure ulcer- full-thickness tissue loss with visible
subcutaneous fat. Bone, tendon, and muscle are not exposed.
stage IV- full thickness tissue loss with exposed bone, tendon, muscle,
bone (slough or eschar may be present within wound bed)
unstageable- contains necrotic tissue, necrotic tissue must be removed
before the wound can be staged.
⩥ While assessing a client's skin, a nurse notices that the skin is dry.
What is the probable etiology of the condition? Select all that apply.
Answer: The use of hard soap and frequent bathing may result in dry
skin. A skin allergy may result in skin rashes, but not dry skin. Using
tanning pills and petroleum products may result in skin cancer.
⩥ The community nurse is assessing an elderly client who lives alone at
home. the client refrains from physical activity for fear of falling when
walking. Which interventions by the nurse are most beneficial to
,promote a healthy lifestyle? Answer: Encourage the client to wear
nonskid shoes.
Suggest that the client use an assistive device.
Help the client rearrange furniture in the house.
⩥ Which features distinguish nursing diagnoses from medical
diagnoses? Select all that apply.
1
Nursing diagnoses involve the client when possible.
2
Nursing diagnoses are based on results of diagnostic tests and
procedures.
3
Nursing diagnoses are the identification of a disease condition in the
client.
4
Nursing diagnoses involve the sorting of health problems within the
nursing domain.
5
Nursing diagnoses involve clinical judgment about the client's response
to health problems. Answer: Nursing diagnoses involve (client
participation) the client when possible.
Nursing diagnoses involve the sorting of health problems within the
nursing domain.
,Nursing diagnoses involve clinical judgment about the client's response
to health problems.
WRONG ANSWER:
Nursing diagnoses are based on results of diagnostic tests and
procedures.
WRONG ANSWER:
Nursing diagnoses are the identification of a disease condition in the
client.
⩥ A 50-year-old client with a 30-year history of smoking reports a
chronic cough and shortness of breath related to chronic obstructive
pulmonary disease (COPD). The clinical data on admission are as
follows: a heart rate of 100, a blood pressure of 138/82, a respiratory rate
of 32, a tympanic temperature 36.8 °C, and an oxygen saturation of
80%. Which vital signs obtained by the nurse during the therapy
indicates a positive outcome? Select all that apply.
1
Radial pulse: 70
2
Temperature: 37 °C
3
Respiratory rate: 14
4
Blood pressure: 110/70
, 5
Oxygen saturation: 96% Answer: 3,4,5
Why not 1&2? The radial pulse indicates a positive outcome of the
therapy if the client has a history of heart disease. A body temperature
reading of 36.8 °C is considered normal and not a sign of COPD.
⩥ Which client is at an increased risk for right-sided heart failure?
Client A:
R Jugular Venous Pressure: 2.5 cm
L Jugular Venous Pressure: 3.0 cm
Client B:
RJVP = 2.0
LJVP = 1.5
Client C:
RJVP = 1.5
LJVP = 1.0 Answer: Client A
Bilateral pressures higher than 2.5 cm are considered elevated and are a
sign of right-sided heart failure. Client A has both right and left jugular