NACE Foundations of Nursing 5 — Questions and Answers
Question 1: A nurse is assessing a patient's skin turgor. The nurse pinches the skin on the back of the hand and it returns to place in 4 seconds. This finding suggests:
- Normal hydration status
- Fluid volume excess
- Dehydration or decreased skin elasticity (Correct answer)
- Adequate tissue perfusion
Correct answer: Dehydration or decreased skin elasticity
Normal skin turgor returns within 2 seconds; a return time of 4 seconds indicates decreased turgor, suggesting dehydration or reduced skin elasticity (common in elderly patients).
Question 2: Which intervention is the nurse's highest priority when caring for a postoperative patient in the PACU who has a SpO₂ of 89%?
- Notify the surgeon immediately
- Encourage the patient to cough and deep breathe
- Apply supplemental oxygen and reposition the airway (Correct answer)
- Document the finding and continue monitoring
Correct answer: Apply supplemental oxygen and reposition the airway
Applying supplemental oxygen and opening the airway addresses the immediate physiologic threat of hypoxemia before notifying the provider.
Question 3: A nurse is caring for a patient on contact precautions. In what order should PPE be removed after leaving the room?
- Gloves, gown, mask/eye protection, hand hygiene (Correct answer)
- Mask/eye protection, gown, gloves, hand hygiene
- Gown, gloves, mask/eye protection, hand hygiene
- Gloves, mask/eye protection, gown, hand hygiene
Correct answer: Gloves, gown, mask/eye protection, hand hygiene
CDC guidelines specify removing gloves first (most contaminated), then gown, then mask/eye protection, followed by hand hygiene.
Question 4: Which finding in a patient's health history most increases the risk for developing a pressure injury?
- BMI of 28 and history of hypertension
- Braden Scale score of 12 and urinary incontinence (Correct answer)
- Ambulation with a cane and mild cognitive impairment
- Controlled type 2 diabetes with HbA1c of 6.8%
Correct answer: Braden Scale score of 12 and urinary incontinence
A Braden Scale score of 12 indicates high pressure injury risk, and incontinence exposes skin to moisture, further increasing breakdown risk.
Question 5: A nurse is caring for a patient with a nasogastric tube before administering a tube feeding. Which assessment confirms correct tube placement?
- Aspirating gastric contents and checking pH (pH ≤5.5 confirms gastric placement) (Correct answer)
- Auscultating for a 'whoosh' sound when injecting air
- Placing the distal end of the tube in water and observing for bubbles
- Asking the patient to speak to confirm the tube is not in the airway
Correct answer: Aspirating gastric contents and checking pH (pH ≤5.5 confirms gastric placement)
Checking the pH of aspirated contents (pH ≤5.5 indicates gastric placement) is the most reliable bedside method to confirm NG tube placement.
Question 6: A nurse is preparing to transfer a patient from bed to wheelchair. The patient can bear partial weight. Which action by the nurse is most important for safe transfer?
- Placing the wheelchair at a 90-degree angle to the bed on the patient's weaker side
- Locking the wheelchair brakes and raising the footrests before the transfer (Correct answer)
- Instructing the patient to place both arms around the nurse's neck for support
- Using a wide stance and bending at the waist to maintain balance during the lift
Correct answer: Locking the wheelchair brakes and raising the footrests before the transfer
Locking wheelchair brakes and raising footrests prevents the chair from rolling and eliminates a tripping hazard, which are essential safety steps before any transfer.
Question 7: A nurse is reviewing a patient's advance directive, which designates a healthcare proxy. The patient is now unconscious and the family disagrees with the proxy's decision. The nurse should:
- Follow the family's wishes because they know the patient best
- Consult the ethics committee to resolve the family dispute
- Honor the decisions of the designated healthcare proxy as per the advance directive (Correct answer)
- Defer all decisions to the attending physician
Correct answer: Honor the decisions of the designated healthcare proxy as per the advance directive
A legally designated healthcare proxy has decision-making authority for an incapacitated patient; the nurse must uphold this advance directive even if family members disagree.
NACE Foundations of Nursing 5
A nurse is assessing a patient's skin turgor.
The nurse pinches the skin on the back of the hand and it returns to place in 4 seconds.
This finding suggests: