NACE EXAM
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A nurse is caring for a client who has
not voided for several hours. When per-
cussing the client's bladder to assess for
distention, the nurse should expect to
hear which of these sounds? dullness
-Tympany
-Hyperresonance
-Dullness
-Resonance.
A nurse is preparing to change a client's
sterile dressing. Which actions by the
nurse, if observed, would contaminate
the sterile field?
-The nurse opens the sterile dressing
tray without touching the inner surface of
the wrapper
The nurse spills sterile saline on the ster-
-The nurse removes the indicator tape
ile field.
from a package of sterile 4x4's and
opens the first flap with a motion away
from the nurse's body
-The nurse spills sterile saline on the
sterile field
-The nurse handles the inside of the ster-
ile gown when putting it on.
A nurse removes an indwelling urethral
(Foley) catheter from a client. Six hours
later, the nurse notes that the client
has not voided. Which of these actions
should the nurse take?
-Apply pressure to the client's suprapu-
Run the tap water while the client is on
bic area
the toilet.
-Obtain an order to recatheterize the
client
-Run the tap water while the client is on
the toilet
-Tell the client to call whenever there is
the urge to void.
, NACE EXAM
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A client who is jaundiced reports itch-
ing. To relieve the itching, which of these
measures would be most helpful?
-Having the client wear clothing made
from synthetic fibers
Giving the client sponge baths with tepid
-Giving the client sponge baths with tepid
water several times a day.
water several times a day
-Rubbing the client's skin with diluted al-
cohol
-Exposing the client to the direct rays of
the sun.
A nurse is assigned to care for a client
who has pulmonary tuberculosis and is
coughing. Which of these protective de-
vices should the nurse put on before en-
tering the client's room to give an oral
mask
medication?
-Mask
-Gloves
-Gown
-Eye shield.
A nurse is instructing a client on how to
limit saturated fat intake and increase in-
take of foods high in polyunsaturated fat.
Which of these fats is highest in polyun-
saturated fatty acids? corn oil
-Corn oil
-Vegetable shortening
-Olive oil
-Butter.
A nurse obtains a tympanic electronic
thermometer reading of 97F (36.1C) on
a client who is flushed and warm to
touch. Which of these actions should the Recheck the temperature with another
nurse take next? thermometer
-Return the electronic unit and connect it
to the source to recharge the batteries
-Report the reading to the
, NACE EXAM
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nurse-in-charge
-Recheck the temperature with another
thermometer
-Recheck the temperature in a half-hour.
A nurse who is caring for a client with
a nursing diagnosis of impaired physi-
cal mobility repositions the client every
two hours. Which of these steps of the
nursing process does the nurse demon-
implementing
strate?
-Planning
-Assessing
-Analyzing
-Implementing.
Before nurses obtain information about a
client's sexual health status as part of the
admission assessment, it would be most
important for nurses to assess their own
personal attitudes about sexuality
-interviewing techniques
-gender role identity
-knowledge of sexual reproduction
-personal attitudes about sexuality.
A nurse is caring for a client whose lab-
oratory reports indicate hypernatremia.
Which of these measures should be in-
cluded in this client's plan of care?
increasing fluid intake
-Inserting an indwelling catheter
-Increasing fluid intake
-Elevating the lower extremities
-Monitoring respiratory rate.
A nurse is teaching a client how to
maintain a low-fat diet when dining out
in restaurants. During the interview, the
client gazes out the window without com- Say nothing more until the client makes
ment or question. The nurse should take a verbal response
which of these actions?
-Say nothing more until the client makes
a verbal response
, NACE EXAM
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-Use visual aids to get the client's atten-
tion
-Say, "You don't seem very interested in
this discussion
-"Ask, "Why are you behaving in this hos-
tile manner?"
A nurse prepares to teach a client how
to self-administer injections. The nurse
has planned to teach the client about
the medication during this session. The
client says repeatedly, "You mean I have
to stick myself with a needle?" Which of
these responses would be most support-
ive of the learning process? You're bothered by the thought of inject-
-I see that you're upset, but let's start by ing yourself
discussing what the drug can do for you
-Many people have this same concern,
but it won't be as hard as you expect
-You're bothered by the thought of inject-
ing yourself
-I wonder if you're reacting to the feelings
that people have about illegal drug use.
A client has an order for psyllium hy-
drophilic mucilloid (Metamucil) 1 packet
po qd. Which of these actions is essential
when a nurse is preparing to administer
this medication?
-Prepare the medication with four
Monitor bowel sounds before administra-
ounces of juice
tion.
-Provide special mouth care after med-
ication administration.
-Administer the medication after it stops
effervescing.
-Monitor bowel sounds before adminis-
tration.
A client who is three days postoperative
is refusing to deep breathe and cough
because of incisional discomfort. Which
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