1. A nurse is caring for a client who has not voided for dullness
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.
2. A nurse is preparing to change a client's sterile dress- The nurse spills
ing. Which actions by the nurse, if observed, would sterile saline on
contaminate the sterile field? 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.
3. A nurse removes an indwelling urethral (Foley) Run the tap water
catheter from a client. Six hours later, the nurse notes while the client is
that the client has not voided. Which of these actions on the toilet.
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.
4. A client who is jaundiced reports itching. To relieve Giving the client
the itching, which of these measures would be most sponge baths with
helpful? tepid water sever-
-Having the client wear clothing made from synthetic al times a day.
fibers
-Giving the client sponge baths with tepid water sev-
eral times a day
, NACE EXAM
-Rubbing the client's skin with diluted alcohol
-Exposing the client to the direct rays of the sun.
5. A nurse is assigned to care for a client who has pul- mask
monary 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.
6. A nurse is instructing a client on how to limit satu- corn oil
rated 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.
7. A nurse obtains a tympanic electronic thermometer Recheck the tem-
reading of 97F (36.1C) on a client who is flushed and perature with an-
warm to touch. Which of these actions should the other thermome-
nurse take next? ter
-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.
8. A nurse who is caring for a client with a nursing implementing
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.
, NACE EXAM
9. Before nurses obtain information about a client's sex- personal attitudes
ual health status as part of the admission assess- about sexuality
ment, it would be most important for nurses to assess
their own
-interviewing techniques
-gender role identity
-knowledge of sexual reproduction
-personal attitudes about sexuality.
10. A nurse is caring for a client whose laboratory re- increasing fluid in-
ports indicate hypernatremia. Which of these mea- take
sures should be included in this client's plan of care?
-Inserting an indwelling catheter
-Increasing fluid intake
-Elevating the lower extremities
-Monitoring respiratory rate.
11. A nurse is teaching a client how to maintain a low-fat Say nothing more
diet when dining out in restaurants. During the inter- until the client
view, the client gazes out the window without com- makes a verbal re-
ment or question. The nurse should take which of sponse
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 discus-
sion
-"Ask, "Why are you behaving in this hostile man-
ner?"
12. A nurse prepares to teach a client how to self-ad- You're bothered by
minister injections. The nurse has planned to teach the thought of in-
the client about the medication during this session. jecting yourself
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
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