NCAS Fundamentals 3

Question 1

A nurse is caring for a patient with a stage 2 pressure injury. Which intervention is the highest priority?

Accepted Answer

Reposition the patient every 2 hours

Answer

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:

Accepted Answer

Fluid accumulation in the alveoli

Answer

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?

Accepted Answer

Apply pressure to the puncture site

Answer

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?

Accepted Answer

'I will inhale slowly and deeply to raise the ball or piston.'

Answer

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?

Accepted Answer

Continue monitoring and notify the physician of the finding

Answer

An asymptomatic bradycardic patient should be monitored closely and the physician notified to determine if intervention is needed.

NCAS - Nursing Community Assessment Service Practice Test

NCAS - Nursing Community Assessment Service Practice Test

NCAS Fundamentals 3