Foundations of Nursing Practice Flashcards
6 cards from real NACE practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Foundations of Nursing Practice flashcards as text
Which vital sign change should the nurse report immediately to the healthcare provider?
Answer: Blood pressure of 88/52 mmHg
A blood pressure of 88/52 mmHg indicates hypotension that could signify shock, hemorrhage, or cardiovascular compromise and requires immediate medical attention.
A nurse is preparing to administer an intramuscular injection to an adult. Which site accommodates the largest volume of medication?
Answer: Ventrogluteal site
The ventrogluteal site is the preferred and largest IM injection site for adults, accommodating up to 3 mL and having the least risk of injury to nerves and blood vessels.
When measuring a patient's blood pressure, the nurse obtains a reading during the first Korotkoff sound. This represents which value?
Answer: Systolic pressure
The first Korotkoff sound, heard as a clear tapping, represents the systolic blood pressure, the pressure when the heart ventricles contract.
A patient is ordered strict intake and output monitoring. Which item should the nurse include in the output measurement?
Answer: Emesis
Emesis (vomit) is a measurable fluid output that must be recorded in strict I&O monitoring to accurately track fluid balance.
Which laboratory value requires the nurse to hold the next dose of warfarin and notify the provider?
Answer: INR of 5.8
An INR of 5.8 is critically elevated (therapeutic range for most conditions is 2.0-3.0), indicating a high risk for hemorrhage and requiring immediate provider notification.
A nurse is inserting an indwelling urinary catheter in a female patient. During insertion, urine is not obtained. What should the nurse do?
Answer: Leave the catheter in place and insert a new one into the urethral meatus
If no urine returns, the catheter was likely inserted into the vagina. The nurse should leave it as a landmark, insert a new sterile catheter into the urethral meatus, then remove the misplaced catheter.