ANSWERS) PLUS RATIONALES 2026 Q&A |LATEST EXAM UPDATE 2026/2027..
*Core Domains:*
*- Basic Care and Comfort*
*- Health Promotion and Maintenance*
*- Infection Control and Safety*
*- Management of Care*
*- Pharmacological and Parenteral Therapies*
*- Physiological Adaptation*
*- Psychosocial Integrity*
*- Reduction of Risk Potential*
*The purpose of this practice exam is to comprehensively evaluate foundational nursing knowledge and clinical judgment essential for ent
Section One: Questions 1–100
Question 1
A nurse is preparing to administer an intramuscular injection to an overweight client. Which of the following needles should the nurse select to
ensure deep muscle penetration?
A. 25-gauge, 5/8-inch needle
B. 22-gauge, 1.5-inch needle
C. 18-gauge, 1-inch needle
D. 27-gauge, 0.5-inch needle
🟢 B. 22-gauge, 1.5-inch needle
🔴 RATIONALE: An intramuscular injection for an obese or overweight client requires a longer needle (typically 1.5 to 2 inches) to ensure the
medication passes through the subcutaneous adipose tissue and reaches the deep muscle belly. A 22-gauge needle is appropriate for
standard IM solutions.
Question 2
,A nurse is caring for a client who is post-operative and reports a pain level of 7 on a scale of 0 to 10. The nurse checks the medical record
and notes that an opioid analgesic is prescribed PRN every 4 hours. The last dose was given 3.5 hours ago. Which of the following actions
should the nurse take first?
A. Contact the healthcare provider to request an increase in medication dosage.
B. Administer the medication immediately since the client is in severe pain.
C. Utilize non-pharmacological pain relief measures like repositioning until the medication is due.
D. Document the client's refusal to wait and re-evaluate in 30 minutes.
🟢 C. Utilize non-pharmacological pain relief measures like repositioning until the medication is due.
🔴 RATIONALE: Because the prescribed time interval has not elapsed, the nurse cannot legally administer the medication. Implementing
non-pharmacological interventions like guided imagery, distraction, or safe repositioning is the immediate nursing action to help mitigate pain
before the next scheduled dose is permissible.
Question 3
A nurse is reviewing safety protocols regarding client restraints. In which of the following situations is the application of physical restraints
justified?
A. A confused client repeatedly attempts to pull out an active central venous catheter.
B. An alert client refuses to stay in bed despite fall risk warnings.
C. A client is extremely verbal and loud, disrupting other clients on the unit.
D. A client diagnosed with dementia wanders into the hallway looking for the bathroom.
🟢 A. A confused client repeatedly attempts to pull out an active central venous catheter.
🔴 RATIONALE: Restraints are a measure of last resort used only when a client poses an immediate threat to their own physical safety or
the safety of others. Pulling out a central venous line presents an immediate life-threatening risk due to potential hemorrhage or air embolism.
Question 4
A nurse is caring for a client who is on strict airborne precautions. Which of the following personal protective equipment (PPE) items must the
nurse don prior to entering the client's room?
A. Surgical mask
B. N95 respirator
C. Gown and clean gloves
D. Face shield
🟢 B. N95 respirator
🔴 RATIONALE: Airborne precautions are required for infectious agents that remain suspended in the air over long distances, such as
tuberculosis, varicella, or rubeola. An N95 or higher-level respirator is mandatory to filter out these microscopic airborne particles.
Question 5
A nurse is reviewing the concept of informed consent with a newly licensed nurse. Which of the following statements by the newly licensed
nurse indicates an understanding of their role?
A. It is my responsibility to fully explain the risks and benefits of the surgical procedure to the client.
B. I must ensure the client understands alternative treatment options before they sign.
, C. My signature as a witness verifies that the client is competent and signed the form voluntarily.
D. If the client changes their mind after signing, I must convince them to proceed for their own health.
🟢 C. My signature as a witness verifies that the client is competent and signed the form voluntarily.
🔴 RATIONALE: The nurse's role in informed consent is to witness the client's signature, confirming that the signature is authentic, the client
appears competent, and that the consent was given voluntarily. The provider performing the procedure carries the legal responsibility to
explain risks, benefits, and alternatives.
Question 6
A nurse is performing a physical assessment on an older adult client. Which of the following skin findings should the nurse document as an
expected age-related change?
A. Increased skin elasticity and turgor
B. Presence of asymmetric, irregular moles
C. Decreased subcutaneous fat thickness
D. Generalized moistness and increased diaphoresis
🟢 C. Decreased subcutaneous fat thickness
🔴 RATIONALE: Normal physiological aging includes the loss of subcutaneous fat, thinning of the dermis, and a decrease in skin elasticity
(leading to tenting or wrinkles). Asymmetric moles are suspicious for malignancy, not normal aging.
Question 7
A nurse is preparing to perform tracheostomy care for a client. Which of the following actions should the nurse plan to take during the
procedure?
A. Use clean technique when cleaning the inner cannula.
B. Apply suction continuously while inserting the suction catheter into the airway.
C. Clean the stoma site using a circular motion moving from the outside inward.
D. Secure new tracheostomy ties before removing the old ties if performing the procedure alone.
🟢 D. Secure new tracheostomy ties before removing the old ties if performing the procedure alone.
🔴 RATIONALE: To prevent accidental extubation or dislodgement of the tracheostomy tube, the nurse should always keep the tube secure.
If working alone, securing the new ties before untying or removing the old ones ensures continuous stabilizing control.
Question 8
A nurse enters a client's room and discovers a fire burning in a wastebasket. Arrange the following actions in the priority order the nurse
should perform them according to the RACE acronym.
Extinguish the fire using an appropriate extinguisher.
Close the doors and windows to contain the fire.
Remove the client from immediate danger.
Activate the facility fire alarm system.
A. 3, 4, 2, 1