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

A blood pressure of 88/52 mmHg indicates hypotension that could signify shock, hemorrhage, or cardiovascular compromise and requires immediate medical attention.

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

The ventrogluteal site is the preferred and largest IM injection site for adults, accommodating up to 3 mL and having the least risk of injury to nerves and blood vessels.

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

The first Korotkoff sound, heard as a clear tapping, represents the systolic blood pressure, the pressure when the heart ventricles contract.

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

Emesis (vomit) is a measurable fluid output that must be recorded in strict I&O monitoring to accurately track fluid balance.

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

An INR of 5.8 is critically elevated (therapeutic range for most conditions is 2.0-3.0), indicating a high risk for hemorrhage and requiring immediate provider notification.

Nursing Acceleration Challenge Exam (NACE) I PN-RN Practice Test

Nursing Acceleration Challenge Exam (NACE) I PN-RN Practice Test

NACE Foundations of Nursing Practice 2