Nace Foundation of Nursing

Free preview · Original latest version

Sample questions from Nace Foundation of Nursing

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

1. 1.At 0700 on a medical-surgical unit, a 76-year-old client with pneumonia has a temperature of 38.1 C, HR 104/min, RR 24/min, BP 118/68 mm Hg, and SpO2 91% on room air. The charge nurse is assigning care to an RN, an LPN, and a nursing assistant. Which task is appropriate to delegate to the nursing assistant?

   • A.Evaluate whether the prescribed oxygen therapy is effective.
   • B.Teach the client how to use the incentive spirometer.
   • C.Assess the client's breath sounds after the first antibiotic dose.
   • D.Obtain and report the client's routine temperature and oxygen saturation.

   Rationale: Obtaining routine vital signs and reporting the results is an appropriate task for a nursing assistant when the client is stable enough for routine data collection. Assessment, teaching, and evaluation require nursing judgment and remain the RN's responsibility. The RN must promptly interpret and act on abnormal results.

2. 2.In a community clinic, a 54-year-old client with newly diagnosed type 2 diabetes says, "I cannot afford the medication or healthy food." Which action should the nurse take first?

   • A.Tell the client to follow the prescribed plan until the next appointment.
   • B.Provide a standard diabetic meal plan.
   • C.Ask about the client's specific financial and access barriers.
   • D.Document that the client is nonadherent.

   Rationale: Exploring the client's specific barriers is the first step toward an individualized and feasible care plan. Giving generic instructions does not address the stated problem, and labeling the client nonadherent is judgmental and premature. The nurse can then collaborate with the provider and social services on affordable treatment and food resources.

3. 3.At change of shift in a long-term care facility, an RN receives report on four residents. Which resident should the RN assess first?

   • A.A 79-year-old with chronic arthritis requesting the usual morning analgesic
   • B.A 68-year-old who is newly confused and has an oxygen saturation of 88% on room air
   • C.An 82-year-old with dementia who has not had a bowel movement for 2 days
   • D.A 90-year-old awaiting assistance with a routine morning bath

   Rationale: New confusion with hypoxemia may indicate acute deterioration and requires immediate assessment. Chronic arthritis, a short period without a bowel movement, and a delayed bath are lower-priority concerns. The nurse should assess airway and breathing, verify oxygenation, and escalate care as indicated.

4. 4.On a medical-surgical unit, a 68-year-old client with heart failure is being discharged after treatment for fluid overload. The client has a BP of 126/74 mm Hg and can explain the medication schedule. Which actions are appropriate for the RN to include in discharge planning? Select all that apply.

   • A.Ask the client to describe when to report worsening symptoms.
   • B.Use teach-back to verify the client's understanding of daily weight monitoring.
   • C.Arrange follow-up care according to the discharge plan.
   • D.Confirm that the client can obtain the prescribed medications.
   • E.Document that the client received instructions without checking understanding.

   Answer and rationale are in the full material.

5. 5.A provider prescribes a medication dose that appears substantially higher than the usual dose for a 7-year-old child in the pediatric clinic. The child weighs 22 kg and is stable. What should the nurse do?

   • A.Hold the medication and clarify the prescription with the provider.
   • B.Ask the parent whether the child has received this dose before.
   • C.Administer the dose because it is a signed prescription.
   • D.Give half the prescribed dose and document the change.

   Answer and rationale are in the full material.