NACE FOUNDATIONS OF NURSING EXAM 1 and 2
Complete Bundle
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
Complete Bundle
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
