Nace

Free preview · Original latest version

Sample questions from Nace

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.A 72-year-old client is admitted to a medical-surgical unit with pneumonia. The client is newly confused, has a temperature of 39.1 C (102.4 F), heart rate 124/min, respirations 30/min, blood pressure 84/48 mm Hg, and oxygen saturation 90% on room air. Which action should the nurse take first?

   • A.A. Obtain a sputum culture before giving antibiotics
   • B.B. Activate the rapid response system and support oxygenation
   • C.C. Administer the prescribed antipyretic
   • D.D. Reassess the client's orientation in 30 minutes

   Rationale: Hypotension, tachycardia, tachypnea, fever, and acute confusion suggest sepsis with possible shock, so immediate escalation and support of airway and breathing are priorities. Obtaining a culture is appropriate when it will not delay urgent stabilization, while an antipyretic does not address impaired perfusion. Waiting to reassess risks deterioration; the exam takeaway is to recognize instability and escalate promptly.

2. 2.A 58-year-old client with a recent stroke is on a neurologic unit and has right-sided weakness and difficulty following instructions. The nurse must delegate care for the shift. Which task is appropriate to assign to an experienced unlicensed assistive personnel (UAP)?

   • A.A. Evaluate whether the client's swallowing is safe
   • B.B. Assist the client with a previously assessed bed-to-chair transfer using a gait belt
   • C.C. Determine whether the client's weakness has worsened
   • D.D. Teach the client how to use the call light before getting up

   Rationale: An experienced UAP may assist with a routine transfer when the nurse has assessed the client and the transfer method is established. Swallowing evaluation and neurologic assessment require nursing judgment, and teaching is the nurse's responsibility. The takeaway is to delegate predictable tasks, not assessment, evaluation, or teaching.

3. 3.A 46-year-old client in the emergency department has crushing chest pain radiating to the jaw, diaphoresis, and nausea. Blood pressure is 152/88 mm Hg, heart rate 104/min, and oxygen saturation 96% on room air; the initial ECG shows ST-segment elevation. Which action should the nurse take first?

   • A.A. Give the prescribed chewable aspirin
   • B.B. Apply oxygen at 2 L/min by nasal cannula
   • C.C. Obtain a detailed family history
   • D.D. Encourage the client to walk to reduce anxiety

   Rationale: Chewable aspirin should be given promptly for suspected acute myocardial infarction unless contraindicated, because it limits platelet aggregation. Routine oxygen is not indicated when saturation is adequate, and a family history can be obtained after immediate treatment begins. Ambulation increases cardiac workload and is unsafe; the takeaway is to prioritize time-sensitive therapies.

4. 4.A 34-year-old client with asthma arrives at urgent care with wheezing, accessory muscle use, and oxygen saturation of 89% on room air. The client is alert and speaks in short phrases. Which prescribed treatment should the nurse implement first?

   • A.A. Administer the short-acting inhaled bronchodilator
   • B.B. Teach the client how to use a peak-flow meter
   • C.C. Give the inhaled corticosteroid scheduled for bedtime
   • D.D. Encourage oral fluids and reassess in 1 hour

   Answer and rationale are in the full material.

5. 5.A 67-year-old client with type 1 diabetes is on a medical unit and is diaphoretic, shaky, and confused before lunch. Capillary glucose is 48 mg/dL; the client is awake and can swallow. Which action should the nurse take?

   • A.A. Give 15 g of a rapid-acting oral carbohydrate and recheck glucose in 15 minutes
   • B.B. Administer the scheduled rapid-acting insulin before the meal
   • C.C. Give glucagon intramuscularly and withhold all oral intake
   • D.D. Recheck the glucose after the client finishes lunch

   Answer and rationale are in the full material.