NACE Foundations of Nursing 3 — Questions and Answers
Question 1: A nurse is preparing to perform a sterile dressing change. Which action breaks sterile technique?
- Reaching across the sterile field without touching it
- Placing sterile items at the edge of the sterile drape (1 inch border) (Correct answer)
- Pouring sterile solution from a distance of 6 inches above the container
- Considering any sterile package that is wet as contaminated
Correct answer: Placing sterile items at the edge of the sterile drape (1 inch border)
The 1-inch border around a sterile drape is considered contaminated; sterile items must be placed within the interior of the field.
Question 2: Which nursing action best demonstrates the principle of beneficence?
- Allowing a patient to refuse a prescribed treatment
- Administering ordered pain medication before a painful procedure (Correct answer)
- Keeping patient information confidential
- Obtaining informed consent before a procedure
Correct answer: Administering ordered pain medication before a painful procedure
Beneficence means acting in the patient's best interest; proactively managing pain before a procedure promotes well-being.
Question 3: A patient's chart shows a temperature of 38.9°C. What is the equivalent Fahrenheit temperature?
- 100.4°F
- 101.4°F
- 102.0°F (Correct answer)
- 103.2°F
Correct answer: 102.0°F
Using the formula °F = (°C × 9/5) + 32: (38.9 × 1.8) + 32 = 70.02 + 32 = 102.02°F, which rounds to 102.0°F.
Question 4: When performing a head-to-toe physical assessment, in what order should the nurse assess the abdomen?
- Inspection, palpation, percussion, auscultation
- Auscultation, percussion, palpation, inspection
- Inspection, auscultation, percussion, palpation (Correct answer)
- Palpation, inspection, auscultation, percussion
Correct answer: Inspection, auscultation, percussion, palpation
The abdomen is assessed by inspection first, then auscultation before percussion and palpation to avoid altering bowel sounds.
Question 5: A nurse notes that a patient's urine output has been 80 mL over the past 4 hours. How should the nurse interpret this finding?
- Normal output; no action needed
- Oliguria; requires further assessment and notification of provider (Correct answer)
- Polyuria; fluid restriction should be initiated
- Normal variation during sleep hours
Correct answer: Oliguria; requires further assessment and notification of provider
Normal urine output is at least 30 mL/hour; 80 mL over 4 hours equals only 20 mL/hour, which meets the definition of oliguria and requires provider notification.
Question 6: A patient receiving IV fluids develops redness, warmth, and swelling at the insertion site. The nurse should first:
- Slow the infusion rate and continue monitoring
- Apply a warm compress and reassess in one hour
- Discontinue the IV and remove the catheter (Correct answer)
- Notify the physician before taking any action
Correct answer: Discontinue the IV and remove the catheter
Signs of phlebitis (redness, warmth, swelling) at an IV site require immediate discontinuation of the infusion and removal of the catheter.
Question 7: Which position is most appropriate for a patient who is unconscious and breathing spontaneously to prevent aspiration?
- Supine with head of bed elevated 30 degrees
- Lateral (recovery/side-lying) position (Correct answer)
- Trendelenburg position
- Prone position
Correct answer: Lateral (recovery/side-lying) position
The lateral (recovery) position allows secretions and vomit to drain from the mouth, reducing aspiration risk in an unconscious patient.
NACE Foundations of Nursing 3
A nurse is preparing to perform a sterile dressing change.
Which action breaks sterile technique?