NACE EXAM LATEST UPDATED GRADED A+

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. - ANSWER-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. - ANSWER-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. - ANSWER-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. - ANSWER-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. - ANSWER-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. - ANSWER-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. - ANSWER-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. - ANSWER-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. - ANSWER-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. - ANSWER-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