NACE Foundations of Nursing 4 — Questions and Answers
Question 1: A nurse is teaching a newly licensed nurse about the chain of infection. Which element, if eliminated, would most effectively prevent the spread of infection?
- Susceptible host
- Portal of entry
- Mode of transmission (Correct answer)
- Reservoir
Correct answer: Mode of transmission
Breaking the mode of transmission (e.g., hand hygiene, PPE) is the most practical and effective strategy to interrupt the chain of infection.
Question 2: A patient is ordered 250 mg of amoxicillin. The medication is available as 125 mg/5 mL. How many mL should the nurse administer?
- 5 mL
- 10 mL (Correct answer)
- 15 mL
- 20 mL
Correct answer: 10 mL
Using the formula: (Desired / Have) × Volume = (250 / 125) × 5 mL = 2 × 5 = 10 mL.
Question 3: Which documentation entry best reflects the principles of accurate nursing charting?
- Patient seemed anxious and uncooperative during assessment.
- Patient refused morning medications without stating a reason.
- Patient stated 'I don't want to take those pills' and refused all 0800 medications; provider notified. (Correct answer)
- Patient is non-compliant with medication regimen.
Correct answer: Patient stated 'I don't want to take those pills' and refused all 0800 medications; provider notified.
Accurate charting uses objective, specific, and factual language including direct quotes, actions taken, and follow-up notifications.
Question 4: A nurse is preparing to administer a subcutaneous injection of insulin. Which site should be avoided if the patient exercises the legs immediately after administration?
- Abdomen
- Upper arm
- Thigh (Correct answer)
- Scapular area
Correct answer: Thigh
Insulin absorbed from the thigh is accelerated by leg exercise, which can cause unpredictable hypoglycemia; the abdomen provides the most consistent absorption.
Question 5: A patient has a nursing diagnosis of 'Risk for Falls.' Which intervention is the priority?
- Educate the patient about fall prevention strategies
- Place a fall-risk identification band on the patient
- Keep the call light and personal items within reach and ensure the bed is in the lowest position (Correct answer)
- Document the fall risk assessment in the medical record
Correct answer: Keep the call light and personal items within reach and ensure the bed is in the lowest position
Environmental modifications that reduce the immediate risk of falling—such as lowering the bed and ensuring call light accessibility—are the highest-priority direct safety interventions.
Question 6: When using the SBAR communication tool, which information is included in the 'Background' section?
- The patient's name, room number, and current vital signs
- The nurse's assessment of what is wrong with the patient
- Pertinent medical history, current diagnosis, and recent treatments (Correct answer)
- The specific action or order the nurse is requesting
Correct answer: Pertinent medical history, current diagnosis, and recent treatments
Background in SBAR includes relevant clinical history, diagnosis, and recent treatments that provide context for the situation.
Question 7: A patient reports pain as 8/10 and requests medication. The nurse checks the MAR and finds the PRN analgesic is not due for another 90 minutes. The nurse should first:
- Ask the patient to wait until the medication is due
- Contact the provider to request a one-time dose or order modification
- Administer the medication early since the patient is in severe pain
- Offer non-pharmacological comfort measures and reassess in 30 minutes (Correct answer)
Correct answer: Offer non-pharmacological comfort measures and reassess in 30 minutes
While awaiting medication eligibility, offering non-pharmacological measures (repositioning, distraction, heat/cold) is a safe and appropriate first intervention.
NACE Foundations of Nursing 4
A nurse is teaching a newly licensed nurse about the chain of infection.
Which element, if eliminated, would most effectively prevent the spread of infection?