NACE Foundations of Nursing Practice 2

Question 1

Which vital sign change should the nurse report immediately to the healthcare provider?

Accepted Answer

Blood pressure of 88/52 mmHg

Answer

Oral temperature of 99.0 degrees Fahrenheit

Answer

Pulse rate of 78 beats per minute

Answer

Respiratory rate of 16 breaths per minute

Question 2

A nurse is preparing to administer an intramuscular injection to an adult. Which site accommodates the largest volume of medication?

Accepted Answer

Ventrogluteal site

Answer

Deltoid muscle

Answer

Vastus lateralis

Answer

Dorsogluteal site

Question 3

When measuring a patient's blood pressure, the nurse obtains a reading during the first Korotkoff sound. This represents which value?

Accepted Answer

Systolic pressure

Answer

Diastolic pressure

Answer

Mean arterial pressure

Answer

Pulse pressure

Question 4

A patient is ordered strict intake and output monitoring. Which item should the nurse include in the output measurement?

Accepted Answer

Emesis

Answer

Insensible perspiration

Answer

Food consumed at meals

Answer

Intravenous fluid rate

Question 5

Which laboratory value requires the nurse to hold the next dose of warfarin and notify the provider?

Accepted Answer

INR of 5.8

Answer

INR of 2.5

Answer

PT of 14 seconds

Answer

aPTT of 35 seconds

Question 6

A nurse is inserting an indwelling urinary catheter in a female patient. During insertion, urine is not obtained. What should the nurse do?

Accepted Answer

Leave the catheter in place and insert a new one into the urethral meatus

Answer

Inflate the balloon and wait for urine flow

Answer

Remove the catheter and insert it into the correct opening

Answer

Push the catheter in further until urine appears