NACE EXAM LATEST 2024 ACTUAL EXAM 130
QUESTIONS AND CORRECT DETAILED ANSWERS
WITH RATIONALES (VERIFIED ANSWERS) |ALREADY
GRADED A+
A nurse is caring for a client who has not voided for several hours. When percussing the client's bladder
to assess for distention, the nurse should expect to hear which of these sounds?
-Tympany
-Hyperresonance
-Dullness
-Resonance.
Dullness
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 removes the indicator tape 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 sterile gown when putting it on.
The nurse spills sterile saline on the sterile field.
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 suprapubic area
-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.
Run the tap water while the client is on the toilet.
A client who is jaundiced reports itching. 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 water several times a day
-Rubbing the client's skin with diluted alcohol
-Exposing the client to the direct rays of the sun.
Giving the client sponge baths with tepid water several times a day.
,A nurse is assigned to care for a client who has pulmonary tuberculosis and is coughing. Which of these
protective devices should the nurse put on before entering the client's room to give an oral medication?
-Mask
-Gloves
-Gown
-Eye shield.
Mask
A nurse is instructing a client on how to limit saturated fat intake and increase intake of foods high in
polyunsaturated fat. Which of these fats is highest in polyunsaturated fatty acids?
-Corn oil
-Vegetable shortening
-Olive oil
-Butter.
corn oil
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 nurse take next?
-Return the electronic unit and connect it to the source to recharge the batteries
-Report the reading to the nurse-in-charge
-Recheck the temperature with another thermometer
-Recheck the temperature in a half-hour.
Recheck the temperature with another thermometer
A nurse who is caring for a client with a nursing diagnosis of impaired physical mobility repositions the
client every two hours. Which of these steps of the nursing process does the nurse demonstrate?
-Planning
-Assessing
-Analyzing
-Implementing.
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
-interviewing techniques
-gender role identity
, -knowledge of sexual reproduction
-personal attitudes about sexuality.
personal attitudes about sexuality
A nurse is caring for a client whose laboratory reports indicate hypernatremia. Which of these measures
should be included in this client's plan of care?
-Inserting an indwelling catheter
-Increasing fluid intake
-Elevating the lower extremities
-Monitoring respiratory rate.
increasing fluid intake
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 comment or question. The nurse should take which
of these actions?
-Say nothing more until the client makes a verbal response
-Use visual aids to get the client's attention
-Say, "You don't seem very interested in this discussion
-"Ask, "Why are you behaving in this hostile manner?"
Say nothing more until the client makes a verbal response
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 supportive of the learning process?
-I see that you're upset, but let's start by 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 injecting yourself
-I wonder if you're reacting to the feelings that people have about illegal drug use.
You're bothered by the thought of injecting yourself
A client has an order for psyllium hydrophilic 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 ounces of juice
-Provide special mouth care after medication administration.
-Administer the medication after it stops effervescing.
-Monitor bowel sounds before administration.
Monitor bowel sounds before administration.
QUESTIONS AND CORRECT DETAILED ANSWERS
WITH RATIONALES (VERIFIED ANSWERS) |ALREADY
GRADED A+
A nurse is caring for a client who has not voided for several hours. When percussing the client's bladder
to assess for distention, the nurse should expect to hear which of these sounds?
-Tympany
-Hyperresonance
-Dullness
-Resonance.
Dullness
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 removes the indicator tape 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 sterile gown when putting it on.
The nurse spills sterile saline on the sterile field.
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 suprapubic area
-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.
Run the tap water while the client is on the toilet.
A client who is jaundiced reports itching. 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 water several times a day
-Rubbing the client's skin with diluted alcohol
-Exposing the client to the direct rays of the sun.
Giving the client sponge baths with tepid water several times a day.
,A nurse is assigned to care for a client who has pulmonary tuberculosis and is coughing. Which of these
protective devices should the nurse put on before entering the client's room to give an oral medication?
-Mask
-Gloves
-Gown
-Eye shield.
Mask
A nurse is instructing a client on how to limit saturated fat intake and increase intake of foods high in
polyunsaturated fat. Which of these fats is highest in polyunsaturated fatty acids?
-Corn oil
-Vegetable shortening
-Olive oil
-Butter.
corn oil
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 nurse take next?
-Return the electronic unit and connect it to the source to recharge the batteries
-Report the reading to the nurse-in-charge
-Recheck the temperature with another thermometer
-Recheck the temperature in a half-hour.
Recheck the temperature with another thermometer
A nurse who is caring for a client with a nursing diagnosis of impaired physical mobility repositions the
client every two hours. Which of these steps of the nursing process does the nurse demonstrate?
-Planning
-Assessing
-Analyzing
-Implementing.
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
-interviewing techniques
-gender role identity
, -knowledge of sexual reproduction
-personal attitudes about sexuality.
personal attitudes about sexuality
A nurse is caring for a client whose laboratory reports indicate hypernatremia. Which of these measures
should be included in this client's plan of care?
-Inserting an indwelling catheter
-Increasing fluid intake
-Elevating the lower extremities
-Monitoring respiratory rate.
increasing fluid intake
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 comment or question. The nurse should take which
of these actions?
-Say nothing more until the client makes a verbal response
-Use visual aids to get the client's attention
-Say, "You don't seem very interested in this discussion
-"Ask, "Why are you behaving in this hostile manner?"
Say nothing more until the client makes a verbal response
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 supportive of the learning process?
-I see that you're upset, but let's start by 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 injecting yourself
-I wonder if you're reacting to the feelings that people have about illegal drug use.
You're bothered by the thought of injecting yourself
A client has an order for psyllium hydrophilic 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 ounces of juice
-Provide special mouth care after medication administration.
-Administer the medication after it stops effervescing.
-Monitor bowel sounds before administration.
Monitor bowel sounds before administration.
