Kaplan PN Foundations of Nursing Integrated Assessment
Exam | 200 Practice Questions & Detailed Answers | Latest
2026 Update | A+ Guide
1. A nurse is providing a complete bed bath for a client on strict bed rest. The nurse observes that the
client's skin is dry and flaky. Which action should the nurse take?
A) Apply moisturizing lotion to the dry areas after bathing
B) Use hot water to cleanse the skin more thoroughly
C) Rub the skin vigorously to remove the flaky areas
D) Avoid applying any products to the skin
Answer: A – Applying moisturizing lotion after bathing helps hydrate dry skin and maintain skin integrity.
Hot water can further dry the skin; vigorous rubbing can cause skin breakdown; avoiding products does
not address the dryness.
2. A client has been on bed rest for several days. The nurse is planning care to prevent complications of
immobility. Which intervention should the nurse include to prevent venous thromboembolism?
A) Massage the client's calves twice daily
B) Apply sequential compression devices (SCDs)
C) Encourage the client to dangle legs at the bedside
D) Limit oral fluid intake to reduce edema
Answer: B – Sequential compression devices help prevent venous thromboembolism by promoting
venous return. Massaging calves can dislodge clots. Dangling legs and limiting fluids do not prevent
thromboembolism.
,3. A nurse is preparing to bathe a client who is 2 days postoperative from abdominal surgery. The client
has a midline incision with a dry, intact dressing. Which action by the nurse is most appropriate?
A) Allow the client to shower independently without assistance
B) Assist the client with a complete bed bath using a basin of warm water
C) Provide a partial bed bath and allow the client to perform peri care independently
D) Defer the bath until the surgical dressing is removed
Answer: C – A partial bed bath conserves the client's energy while allowing independence in peri care,
promoting dignity and preserving functional ability. Complete bed baths are for clie nts who cannot
participate. Independent showering is unsafe for a postoperative day 2 client.
4. A client who is bedridden and dependent has been ordered to resume an oral diet. When feeding the
client, the nurse should perform which action first?
A) Offer small bites of food on a spoon
B) Elevate the head of the bed to at least 30 degrees
C) Check the client's gag reflex
D) Place the food tray within the client's reach
Answer: C – Before feeding a client who has been NPO or is at risk for aspiration, the nurse must first
assess the client's gag reflex and swallowing ability to ensure safe ty.
,5. A nurse is caring for an immobile patient who has developed a reddened area over the sacrum that
does not blanch when pressure is applied. The nurse should document this finding as which stage of
pressure ulcer?
A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4
Answer: A – A Stage 1 pressure ulcer is characterized by nonblanchable erythema of intact skin. The area
may be painful, firm, soft, warmer, or cooler compared to adjacent tissue.
6. Which nursing intervention is most important for preventing pressure injuries in an immobile patient?
A) Massage bony prominences to increase circulation
B) Reposition the patient at least every 2 hours
C) Keep the patient in a supine position for comfort
D) Apply a heating pad to increase skin warmth
Answer: B – Repositioning the patient at least every 2 hours is the standard intervention to prevent
pressure injuries by relieving pressure on bony prominences. Massage of bony prominences should be
avoided as it can cause trauma to deep tissues.
7. A patient has a wound with irregular edges and vein bridging at the site. The nurse should document
this wound as which type?
A) Abrasion
, B) Laceration
C) Avulsion
D) Stab wound
Answer: B – A laceration is characterized by irregular edges with tissue bridging (vein bridging).
Abrasions have scraped surfaces, avulsions involve torn tissue, and stab wounds have narrow, deep
tracks.
8. A practical nurse is caring for an 82yearold client on bed rest following a hip fracture. Which
intervention is most important to prevent pressure injuries?
A) Restrict fluid intake to reduce the need for frequent repositioning
B) Reposition the client every 2 hours
C) Massage reddened areas to promote circulation
D) Apply powder to bony prominences daily
Answer: B – Repositioning every 2 hours is the standard intervention to prevent pressure injuries.
Restricting fluids leads to dehydration and skin breakdown. Massaging reddened areas can damage
capillaries and worsen tissue ischemia. Powder can create friction and moisture.
9. A nurse is preparing to perform hand hygiene before entering a patient's room. What is the primary
purpose of hand hygiene in clinical practice?
A) To remove visible dirt from the hands
B) To reduce the transmission of healthcareassociated infections
C) To comply with hospital policy
D) To protect the nurse's skin from drying
Exam | 200 Practice Questions & Detailed Answers | Latest
2026 Update | A+ Guide
1. A nurse is providing a complete bed bath for a client on strict bed rest. The nurse observes that the
client's skin is dry and flaky. Which action should the nurse take?
A) Apply moisturizing lotion to the dry areas after bathing
B) Use hot water to cleanse the skin more thoroughly
C) Rub the skin vigorously to remove the flaky areas
D) Avoid applying any products to the skin
Answer: A – Applying moisturizing lotion after bathing helps hydrate dry skin and maintain skin integrity.
Hot water can further dry the skin; vigorous rubbing can cause skin breakdown; avoiding products does
not address the dryness.
2. A client has been on bed rest for several days. The nurse is planning care to prevent complications of
immobility. Which intervention should the nurse include to prevent venous thromboembolism?
A) Massage the client's calves twice daily
B) Apply sequential compression devices (SCDs)
C) Encourage the client to dangle legs at the bedside
D) Limit oral fluid intake to reduce edema
Answer: B – Sequential compression devices help prevent venous thromboembolism by promoting
venous return. Massaging calves can dislodge clots. Dangling legs and limiting fluids do not prevent
thromboembolism.
,3. A nurse is preparing to bathe a client who is 2 days postoperative from abdominal surgery. The client
has a midline incision with a dry, intact dressing. Which action by the nurse is most appropriate?
A) Allow the client to shower independently without assistance
B) Assist the client with a complete bed bath using a basin of warm water
C) Provide a partial bed bath and allow the client to perform peri care independently
D) Defer the bath until the surgical dressing is removed
Answer: C – A partial bed bath conserves the client's energy while allowing independence in peri care,
promoting dignity and preserving functional ability. Complete bed baths are for clie nts who cannot
participate. Independent showering is unsafe for a postoperative day 2 client.
4. A client who is bedridden and dependent has been ordered to resume an oral diet. When feeding the
client, the nurse should perform which action first?
A) Offer small bites of food on a spoon
B) Elevate the head of the bed to at least 30 degrees
C) Check the client's gag reflex
D) Place the food tray within the client's reach
Answer: C – Before feeding a client who has been NPO or is at risk for aspiration, the nurse must first
assess the client's gag reflex and swallowing ability to ensure safe ty.
,5. A nurse is caring for an immobile patient who has developed a reddened area over the sacrum that
does not blanch when pressure is applied. The nurse should document this finding as which stage of
pressure ulcer?
A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4
Answer: A – A Stage 1 pressure ulcer is characterized by nonblanchable erythema of intact skin. The area
may be painful, firm, soft, warmer, or cooler compared to adjacent tissue.
6. Which nursing intervention is most important for preventing pressure injuries in an immobile patient?
A) Massage bony prominences to increase circulation
B) Reposition the patient at least every 2 hours
C) Keep the patient in a supine position for comfort
D) Apply a heating pad to increase skin warmth
Answer: B – Repositioning the patient at least every 2 hours is the standard intervention to prevent
pressure injuries by relieving pressure on bony prominences. Massage of bony prominences should be
avoided as it can cause trauma to deep tissues.
7. A patient has a wound with irregular edges and vein bridging at the site. The nurse should document
this wound as which type?
A) Abrasion
, B) Laceration
C) Avulsion
D) Stab wound
Answer: B – A laceration is characterized by irregular edges with tissue bridging (vein bridging).
Abrasions have scraped surfaces, avulsions involve torn tissue, and stab wounds have narrow, deep
tracks.
8. A practical nurse is caring for an 82yearold client on bed rest following a hip fracture. Which
intervention is most important to prevent pressure injuries?
A) Restrict fluid intake to reduce the need for frequent repositioning
B) Reposition the client every 2 hours
C) Massage reddened areas to promote circulation
D) Apply powder to bony prominences daily
Answer: B – Repositioning every 2 hours is the standard intervention to prevent pressure injuries.
Restricting fluids leads to dehydration and skin breakdown. Massaging reddened areas can damage
capillaries and worsen tissue ischemia. Powder can create friction and moisture.
9. A nurse is preparing to perform hand hygiene before entering a patient's room. What is the primary
purpose of hand hygiene in clinical practice?
A) To remove visible dirt from the hands
B) To reduce the transmission of healthcareassociated infections
C) To comply with hospital policy
D) To protect the nurse's skin from drying
