COMPLETE QUESTION BANK AND ANSWER
KEY 2026
◉ A nurse is taking notes of client information on a piece of paper
while receiving report. Which of the following actions should the
nurse take to dispose of the paper? Answer: Shred the paper in a
secure container.
Rationality:
The nurse should shred any written information in a secure
container after use to protect the client's privacy and adhere to
HIPAA guidelines.
◉ A nurse is assisting with the care of a recently deceased client.
Which of the following actions should the nurse complete prior to
the family viewing the body? Answer: Clean soiled areas of the body.
Rationality:
A complete bath is not necessary because the body will be washed
by the mortician. The nurse should cleanse any soiled areas prior to
the family viewing the body, make sure dentures are in place if
applicable, and comb the client's hair.
,◉ A nurse is preparing to administer an enteral feeding to a client
who has an NG tube in place. Which of the following methods should
the nurse use to verify correct placement of the NG tube? Answer:
Check the pH of the gastric aspirate
rationality: The nurse should check the pH of the gastric contents to
verify tube placement. A pH greater than 6 is an indication that the
nurse has aspirated respiratory contents or that the tube is in the
intestine, and that the nurse should withhold the feeding.
The nurse should not auscultate over the epigastrium because this is
not a reliable indication that the tube is in place.
The nurse should measure the length of the inserted NG tube
immediately after insertion of the tube. However, measuring the
length of the tube at this point is not a reliable indication that the
tube is in place.
◉ A nurse is caring for a client who has a terminal illness and a
family member asks why the client's mouth is continually open.
Which of the following responses should the nurse make? Answer:
"The reduced muscle tone has relaxed the jaw muscles."
Rationality: Prior to death, decreased muscle tone causes jaw
muscles to relax, resulting in an open mouth.
,Applying a chin strap is a postmortem action that the nurse can take
to keep the mouth closed.
◉ A nurse is caring for a postoperative client who is at risk for
thrombus formation. Which of the following interventions should
the nurse delegate to an assistive personnel (AP)? Answer: Apply
thromboembolic stockings.
Rationality: The application of thromboembolic stockings is within
the range of function of an AP and does not require further data
collection by the nurse.
Reinforcing teaching is not within the range of function of an AP
because it requires the knowledge and skills of the nurse.
◉ A nurse is preparing to collect data from a client for a health
assessment. Which of the following actions should the nurse take?
Answer: Provide privacy for the client.
Rationality: The nurse should promote a therapeutic environment
by providing privacy while data is being collected for a health
assessment.
, ◉ A nurse is planning care for a client who is disoriented and at risk
for falls. Which of the following interventions should the nurse
include? (Select all that apply.) Answer: Ensure that the client is
wearing nonskid slippers.
Rationality: Nonskid slippers provide better traction and can help
prevent slipping and falling.
Place the client in a room near the nurses' station.
Keeping the client close to the nurses' station allows for more
frequent observation to help identify actions that increase the risk
for falls.
Reinforce teaching about how to use the call bell.
Rationality: Even if the client is confused, it is important to reinforce
the use of the call bell for assistance to help prevent the client from
attempting actions that could increase the risk for falls.
◉ A nurse is providing wound care for a group of clients. Which of
the following wounds should the nurse identify as healing by
secondary intention? Answer: A stage 3 pressure injury on the
coccyx