RECENT EXAM 2026|2027 ACTUAL COMPLETE REAL EXAM
QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS)
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A nurse is assessing an older adult's skin. Which intervention is most
appropriate when assessing for subtle color changes in a patient with
darkly pigmented skin?
A. Use only fluorescent lighting
B. Assess the skin only on the palms and soles
C. Use natural lighting and inspect areas such as the conjunctiva and
oral mucosa
D. Compare the patient's skin color with another patient's skin
Answer: C. Use natural lighting and inspect areas such as the
conjunctiva and oral mucosa
Rationale: Natural lighting improves visualization of subtle skin
changes. In patients with darker skin tones, nurses should also assess
areas where changes in color may be easier to detect, such as the
conjunctiva, lips, oral mucosa, palms, and nail beds. Comparing a
patient's skin with another person's skin is inappropriate.
A patient with diabetes mellitus is being assessed during a routine foot
examination. Which finding requires the nurse's greatest concern?
,A. Warm skin
B. Intact toenails
C. A small ulcer on the plantar surface
D. Mildly dry skin
Answer: C. A small ulcer on the plantar surface
Rationale: Patients with diabetes are at increased risk for impaired
circulation, neuropathy, delayed wound healing, and infection. Even a
small ulcer can progress rapidly and requires prompt assessment and
appropriate management.
Which intervention is most appropriate for preventing pressure injury
in an immobile patient?
A. Massage reddened bony prominences
B. Reposition the patient regularly and relieve pressure from
vulnerable areas
C. Keep the head of the bed elevated as high as possible
D. Restrict the patient's fluid intake
Answer: B. Reposition the patient regularly and relieve pressure from
vulnerable areas
Rationale: Pressure injuries develop when prolonged pressure
compromises tissue perfusion. Regular repositioning, pressure
redistribution, moisture management, adequate nutrition, and skin
assessment are essential preventive measures. Massaging reddened
areas can further damage tissue.
,A nurse observes nonblanchable redness over a patient's sacrum. How
should this finding be interpreted?
A. Normal skin variation
B. Stage 1 pressure injury
C. Stage 2 pressure injury
D. Deep tissue infection
Answer: B. Stage 1 pressure injury
Rationale: A Stage 1 pressure injury involves intact skin with
persistent nonblanchable erythema. Early recognition is important
because intervention can prevent progression to deeper tissue injury.
Which patient is at greatest risk for impaired skin integrity?
A. A mobile adult who eats a balanced diet
B. A patient who independently changes position
C. An incontinent, immobile patient with poor nutritional intake
D. A patient who walks three times daily
Answer: C. An incontinent, immobile patient with poor nutritional
intake
Rationale: Immobility causes prolonged pressure, incontinence
increases moisture and skin breakdown, and poor nutrition impairs
tissue repair. Together, these factors substantially increase pressure-
injury risk.
, A patient has difficulty swallowing after a neurologic injury. Which
nursing action is the priority?
A. Offer thin liquids
B. Place the patient flat after meals
C. Request or perform an appropriate swallowing assessment
according to facility policy
D. Encourage the patient to eat rapidly
Answer: C. Request or perform an appropriate swallowing assessment
according to facility policy
Rationale: Dysphagia can result in aspiration, pneumonia,
dehydration, and malnutrition. Assessment of swallowing ability
should occur before providing food or fluids that may place the patient
at risk.
Which position is generally safest for a patient with dysphagia during
meals?
A. Supine
B. Upright
C. Trendelenburg
D. Prone