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(NACE) I PN-RN_ Foundations of Nursing Practice Test
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- Nursing 220 Final Exam Review
(NACE) I PN-RN_ Foundations of Nursing Practice Test
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(NACE) I PN-RN: Foundations of NursingPractice Test
1. An Alzheimer patient is actively resistive to basic hygiene. However, in order to meet
basic standards for hygiene, how frequently should the patient be bathed?
o Daily
o Two to three times weekly
o Biweekly
o Weekly - ANS-While adults don't usually need daily baths, they should bathe two to
three times weekly. Grab bars, shower or tub seats, tub mats, handheld showers, and
proper heating (to avoid chilling the patient) can facilitate more frequent bathing. Mild
soap and bath oil may reduce the drying of skin. Patients who are fearful of tubs and
showers, common with dementia, may receive a sponge bath or Comfort Bath with
premoistened, warmed washcloths. Thick-handled toothbrushes or electric toothbrushes
may facilitate mouth care.
2. At which time of day are patients with cognitive impairment usually MOST sensitive to
sensory overload?
o Noon
o Early morning
o Late evening
o Afternoon - ANS-Many people are more sensitive to sensory overload in the afternoon
when cortisol levels are highest. Sensory overload most often affects those with
cognitive impairment or those in stressful situations. Excess noise and activity can
cause distress, agitation, confusion, and delirium. Sensory deprivation occurs when
there is too little environmental stimulation because of reduction in sensory input
because of hearing or vision deficits, inability to recognize sensory input because of
cognitive impairment, or a boring environment. Sensory deprivation can contribute to
confusion, disorientation, and depression.
3. Which of the following is characteristic of nociceptive pain?
o Association with chronic conditions such as diabetes or cancer
o Diffuse or cramping pain
o Burning, stabbing, or shooting pains
o Acute aching or throbbing pain localized to the site of injury - ANS-Nociceptive pain
usually correlates with the extent and type of injury: the greater the injury, the greater
the pain. It may be procedural pain (related to wound manipulation and dressing
changes) or surgical pain (related to the cutting of tissue). It may also be continuous or
, cyclic, depending upon the type of injury. This type of pain, often described as aching or
throbbing, is usually localized to the area of injury and resolves over time as healing
takes place, and it usually responds to analgesia.
4. According to the three-step World Health Organization (WHO) "analgesic ladder," a
patient complaining of moderate to severe pain unresponsive to NSAIDs may require
which of the following medications?
o Acetaminophen
o Demerol
o Codeine
o Morphine - ANS-Codeine. Systemic medications may be given orally or by injection
into muscles, subcutaneous tissue, or veins to control pain. World Health Organization
(WHO) pain classifications include the following:
• Step 1: Mild to moderate pain is treated with aspirin, acetaminophen, and NSAIDs.
• Step 2: Moderate to severe pain unrelieved by Step 1 medications may need opioids,
such as codeine, tramadol, or Percocet.
• Step 3: Severe pain without relief from Step 1 or Step 2 medications may need
stronger opioids, such as morphine, Dilaudid, or MS-Contin.
5. Which type of precautions is indicated for a patient with a surgical-site infection and
purulent discharge?
o Contact
o Contact and droplet
o Airborne
o Droplet - ANS-Contact precautions
6. Which of the following injection sites is the BEST choice for intramuscular (IM)
administration of 3 mL of medication for a well-developed adult female of normal
weight?
o Dorsogluteal site
o Ventrogluteal site
o Vastus lateralis
o Deltoid - ANS-The ventrogluteal site is the preferred IM injection site because there is
little danger of injecting into fatty tissue, large nerves, or blood vessels. In a
well-developed adult, up to 4 mL can be safely injected. The dorsogluteal site is the
least preferred site because of its proximity to the sciatic nerve and large blood vessels
and increased fat deposits. The vastus lateralis site is also good because it lacks large
nerves or large blood vessels. The deltoid site is usually avoided because of the small
muscle size and the proximity of the radial nerve and artery. Injections to the deltoid
should be limited to 1 mL.
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