NACE Foundations of Nursing 5

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:

Accepted Answer

Dehydration or decreased skin elasticity

Answer

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%?

Accepted Answer

Apply supplemental oxygen and reposition the airway

Answer

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?

Accepted Answer

Gloves, gown, mask/eye protection, hand hygiene

Answer

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?

Accepted Answer

Braden Scale score of 12 and urinary incontinence

Answer

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?

Accepted Answer

Aspirating gastric contents and checking pH (pH ≤5.5 confirms gastric placement)

Answer

Checking the pH of aspirated contents (pH ≤5.5 indicates gastric placement) is the most reliable bedside method to confirm NG tube placement.

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

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

NACE Foundations of Nursing 5