Mixed Deck — All NACE Topics Flashcards

A nurse is preparing to administer IV medications to two patients simultaneously. Which action BEST prevents medication errors?

Answer: Label each syringe and verify at the bedside using two patient identifiers

Labeling syringes and verifying two patient identifiers at the bedside is the standard practice to prevent medication errors.

During the assessment phase of the nursing process, the nurse gathers both subjective and objective data. Which of the following is an example of subjective data?

Answer: The client's statement, "I have a pounding headache."

Subjective data is information provided by the client from their own perspective, such as their feelings, perceptions, and concerns. It cannot be directly measured by the healthcare provider. The statement "I have a pounding headache" is what the client is reporting. Blood pressure, heart rate, and observed grimacing are all forms of objective data that can be seen, measured, or observed by the nurse.

A nurse reviews morning labs: Na+ 140 mEq/L, K+ 3.2 mEq/L, Cl- 98 mEq/L, HCO3- 28 mEq/L. Which imbalance does the nurse identify?

Answer: Hypokalemia

The normal serum potassium range is 3.5–5.0 mEq/L; a potassium level of 3.2 mEq/L indicates hypokalemia, which can cause dysrhythmias, muscle weakness, and constipation.

A nurse is assessing a 3-year-old who insists on doing tasks 'by myself.' According to Erikson, this behavior reflects which developmental stage?

Answer: Autonomy vs. shame and doubt

Autonomy vs. shame and doubt occurs from ages 1–3 and is characterized by the toddler's drive for independence.

Which assessment finding in a patient with a new hip fracture fixation requires immediate nursing intervention?

Answer: Foot on the affected side is cool, pale, and pulses are absent

Absent pulses, pallor, and coolness in the affected extremity indicate compromised neurovascular status, possibly from compartment syndrome or vascular injury requiring emergent intervention.

Which nursing intervention is most important when caring for a patient with a chest tube?

Answer: Maintain the drainage system below the level of the chest

The chest tube drainage system must be kept below chest level at all times to prevent backflow of fluid into the pleural space and maintain proper drainage.

A nurse notices a client has been isolating herself and crying frequently since her husband's death two weeks ago. The nurse's best initial action is to:

Answer: Sit with the client and offer presence without pressure to talk

Offering therapeutic presence acknowledges the client's grief and communicates support without imposing expectations.

A patient on mechanical ventilation has a PaCO2 of 55 mmHg and pH of 7.28. The ventilator rate is 12 breaths/min. What adjustment would correct the respiratory acidosis?

Answer: Increase the respiratory rate

Increasing the respiratory rate increases minute ventilation, eliminating more CO2 and correcting respiratory acidosis.

A nurse is creating a plan of care for a client newly diagnosed with an acute deep vein thrombosis (DVT) in the left leg. Which of the following nursing interventions should be included in the plan?

Answer: Elevating the affected extremity while the client is in bed.

For a client with an acute DVT, elevating the affected leg is recommended to promote venous return by gravity, which helps decrease edema and pain. Massaging the leg, applying SCDs to the affected limb, and performing active range-of-motion exercises are contraindicated as they can dislodge the thrombus, potentially leading to a life-threatening pulmonary embolism.

A patient has experienced 48 hours of acute vomiting and watery diarrhea. Which electrolyte imbalance is most likely to happen when vomiting and diarrhea are persistent?

Answer: Hyponatremia.

Persistent vomiting and watery diarrhea lead to significant loss of both water and electrolytes from the body. Sodium is a major electrolyte lost in gastrointestinal fluids, and its depletion without adequate replacement commonly results in hyponatremia, which is a dangerously low level of sodium in the blood.

A nurse is caring for a patient with a central venous catheter. Which complication should the nurse monitor for during and immediately after insertion?

Answer: Pneumothorax

Pneumothorax is an acute complication of central venous catheter insertion, particularly with subclavian or internal jugular approaches, caused by accidental lung puncture.

Which electrolyte imbalance is most commonly associated with prolonged loop diuretic therapy such as furosemide?

Answer: Hypokalemia

Loop diuretics inhibit potassium reabsorption in the loop of Henle, making hypokalemia the most common electrolyte complication.

A nurse is teaching a 45-year-old female client about recommended health screenings. Which screening should the nurse prioritize for this age group?

Answer: Annual mammogram

The American Cancer Society recommends annual mammograms for average-risk women beginning at age 45.

Which medication requires the nurse to monitor for ototoxicity as a serious adverse effect?

Answer: Gentamicin

Gentamicin is an aminoglycoside antibiotic with well-documented ototoxic and nephrotoxic effects. Peak and trough levels must be monitored.

A patient with heart failure is prescribed furosemide. Which electrolyte imbalance is the priority concern?

Answer: Hypokalemia

Loop diuretics like furosemide inhibit sodium-potassium-chloride reabsorption in the loop of Henle, causing significant potassium wasting and hypokalemia.

A nurse receives a telephone order from a physician. Which step is most important to ensure accuracy?

Answer: Read the order back to the physician and receive confirmation

Read-back verification — repeating the order to the prescriber and receiving confirmation — is the required safety step for telephone orders.

A nurse is caring for a client receiving furosemide for heart failure. The client reports significant muscle weakness, and the cardiac monitor shows flattened T waves and prominent U waves. The nurse should suspect which electrolyte imbalance?

Answer: Hypokalemia

Furosemide is a loop diuretic that can cause significant potassium loss. Muscle weakness, fatigue, and cardiac dysrhythmias are classic signs of hypokalemia. The characteristic ECG changes associated with hypokalemia include flattened or inverted T waves, prominent U waves, and ST-segment depression.

A patient's durable power of attorney for healthcare (DPAHC) designates a spouse as surrogate decision-maker. The patient is now unconscious. The adult children disagree with the spouse's decision. Who has legal authority?

Answer: The spouse designated in the DPAHC

The legally designated healthcare proxy in a DPAHC holds decision-making authority over all family members who are not designated.

A nurse is caring for a client with Medicare. Which statement about Medicare Part B is accurate?

Answer: It covers outpatient physician services and preventive care

Medicare Part B covers outpatient services, physician visits, preventive care, and durable medical equipment, and requires a monthly premium.

A nurse discovers that a patient's advance directive specifies no resuscitation, but the physician has entered a full-code order. What is the nurse's BEST action?

Answer: Notify the physician of the discrepancy and escalate to the charge nurse or supervisor if unresolved

A conflict between an advance directive and a physician order requires immediate clarification through the chain of command to protect the patient's legal rights.