NCAS Fundamentals 3 — Questions and Answers
Question 1: A nurse is caring for a patient with a stage 2 pressure injury. Which intervention is the highest priority?
- Apply a wet-to-dry dressing
- Reposition the patient every 2 hours (Correct answer)
- Administer prescribed antibiotics
- Massage the reddened area to increase circulation
Correct answer: Reposition the patient every 2 hours
Repositioning every 2 hours relieves pressure and is the cornerstone intervention for preventing worsening of pressure injuries.
Question 2: During a head-to-toe assessment, the nurse auscultates the lungs and hears crackles (rales) in the bases bilaterally. This finding is most consistent with:
- Bronchospasm
- Fluid accumulation in the alveoli (Correct answer)
- Pleural friction rub
- Normal breath sounds in elderly patients
Correct answer: Fluid accumulation in the alveoli
Bilateral basilar crackles are associated with fluid in the alveoli, as seen in pulmonary edema or heart failure.
Question 3: A nurse is preparing to perform a blood glucose finger-stick. After obtaining the blood sample, what is the next action?
- Recap the lancet and dispose in the trash
- Apply pressure to the puncture site (Correct answer)
- Immediately document the result before reading it
- Wipe the finger with alcohol before applying pressure
Correct answer: Apply pressure to the puncture site
Applying pressure to the puncture site stops bleeding and prevents hematoma formation at the capillary puncture site.
Question 4: Which statement by a patient indicates a correct understanding of incentive spirometry use?
- 'I will use it once a day after meals.'
- 'I will inhale slowly and deeply to raise the ball or piston.' (Correct answer)
- 'I should exhale forcefully into the device.'
- 'I will use it only when I feel short of breath.'
Correct answer: 'I will inhale slowly and deeply to raise the ball or piston.'
Incentive spirometry requires slow, sustained maximal inspiration to fully expand the lungs and prevent atelectasis.
Question 5: A patient's telemetry shows a heart rate of 48 bpm with regular rhythm. The patient is asymptomatic. What is the nurse's priority action?
- Immediately call a code
- Continue monitoring and notify the physician of the finding (Correct answer)
- Administer atropine per protocol
- Increase the IV fluid rate
Correct answer: Continue monitoring and notify the physician of the finding
An asymptomatic bradycardic patient should be monitored closely and the physician notified to determine if intervention is needed.
Question 6: When assessing a patient's pain, which tool is most appropriate for a patient who is intubated and unable to speak?
- Numeric Rating Scale (NRS) 0-10
- Behavioral Pain Scale (BPS) (Correct answer)
- Wong-Baker FACES Scale
- McGill Pain Questionnaire
Correct answer: Behavioral Pain Scale (BPS)
The Behavioral Pain Scale assesses pain through observable behaviors such as facial expressions and limb movements in non-verbal patients.
Question 7: A patient refuses a prescribed medication. What is the most appropriate nursing action?
- Crush the medication and place it in food or drink
- Inform the patient of the consequences and document the refusal (Correct answer)
- Call security to ensure the patient takes the medication
- Administer the medication anyway since it is prescribed
Correct answer: Inform the patient of the consequences and document the refusal
Competent patients have the right to refuse treatment; the nurse should educate, respect the decision, and document the refusal.
NCAS Fundamentals 3
A nurse is caring for a patient with a stage 2 pressure injury.
Which intervention is the highest priority?