NACE Foundations of Nursing Practice 5

Question 1

A nurse is preparing to insert a urinary catheter. Which action is essential to maintain sterile technique?

Accepted Answer

Keep sterile gloved hands above waist level at all times

Answer

Sterile gloved hands must remain above waist level and within the nurse's field of vision to be considered sterile.

Question 2

A client's morning blood glucose is 52 mg/dL and they are conscious and able to swallow. What is the nurse's first action?

Accepted Answer

Give 15–20 grams of fast-acting carbohydrates orally

Answer

The '15-15 rule' directs the nurse to give 15–20 g of fast-acting carbohydrates orally to a conscious hypoglycemic client first.

Question 3

Which client statement indicates a correct understanding of incentive spirometry after abdominal surgery?

Accepted Answer

'I will take a slow deep breath in and hold it for 3–5 seconds.'

Answer

Correct incentive spirometry technique involves a slow maximal inhalation followed by a 3–5 second breath-hold to open alveoli.

Question 4

A nurse applies a wet-to-dry dressing to a wound. What is the primary purpose of this dressing type?

Accepted Answer

Mechanically debride necrotic tissue as the dressing dries

Answer

Wet-to-dry dressings adhere to necrotic debris when wet, and removal of the dry dressing mechanically debrides the wound.

Question 5

A client's urine output for the past 8 hours totals 200 mL. How should the nurse document this finding?

Accepted Answer

Oliguria

Answer

Oliguria is defined as urine output less than 30 mL/hour or less than 400 mL/day; 200 mL in 8 hours (25 mL/hr) meets this criterion.

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