NACE PN TO RN EXAM WITH PRECISE |! |! |! |! |! |! |!
DETAILED ANSWERS |!
To evaluate a client's reason for seeking care, the nurse performs deep
|! |! |! |! |! |! |! |! |! |! |! |!
palpation. The purpose of deep palpation is to assess which of the following?
|! |! |! |! |! |! |! |! |! |! |! |! |!
- Correct answer ✔Correct Answer: Organs
|! |! |! |! |!
The purpose of deep palpation, in which the nurse indents the client's skin
|! |! |! |! |! |! |! |! |! |! |! |! |!
approximately 1-1/2", is to assess underlying organs and structures such as |! |! |! |! |! |! |! |! |! |! |!
the kidneys and spleen. Skin turgor, hydration, and temperature can be
|! |! |! |! |! |! |! |! |! |! |!
assessed using light touch or light palpation.
|! |! |! |! |! |!
A client is brought to the emergency department and the physician
|! |! |! |! |! |! |! |! |! |! |!
determines he has gastrointestinal (GI) bleeding. In planning for his care,
|! |! |! |! |! |! |! |! |! |! |!
which of the following would be first priority? - Correct answer ✔The Correct
|! |! |! |! |! |! |! |! |! |! |! |!
answer is: assessment of vital signs Vital sign assessment would be the
|! |! |! |! |! |! |! |! |! |! |! |! |!
priority nursing intervention. This would provide an indication of the amount
|! |! |! |! |! |! |! |! |! |!
of blood loss that has occurred and also provide a baseline by which to
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
monitor the progress of treatment. The other answers (b, c, and d) are
|! |! |! |! |! |! |! |! |! |! |! |! |!
important but not priority actions. |! |! |! |!
When providing instructions to the adolescent regarding physical
|! |! |! |! |! |! |! |!
development of her body, the RN should do all of the following EXCEPT - |! |! |! |! |! |! |! |! |! |! |! |! |! |!
Correct answer ✔Correct Answer: Discuss the importance of avoiding social
|! |! |! |! |! |! |! |! |! |!
events in order to stay out of trouble.
|! |! |! |! |! |! |!
Socialization is very important to teenagers and is a normal part of their |! |! |! |! |! |! |! |! |! |! |! |! |!
development. The other answers (b, c, and d) are all accurate instructions |! |! |! |! |! |! |! |! |! |! |! |!
and discussions for the adolescent regarding development.
|! |! |! |! |! |!
,The nurse is developing discharge plans for a 65-year-old client. The
|! |! |! |! |! |! |! |! |! |! |!
discharge plans indicate the client will be discharged home with home health
|! |! |! |! |! |! |! |! |! |! |!
nursing care. The nurse provides the home health agency with details
|! |! |! |! |! |! |! |! |! |! |! |!
regarding the needs of the patient. The nurse made which of the following to
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
the home health agency? - Correct answer ✔Correct answer: A referral. A
|! |! |! |! |! |! |! |! |! |! |! |!
referral is recommending home care services or giving information to an
|! |! |! |! |! |! |! |! |! |! |!
home care service regarding the client and the client's needs. Typically the
|! |! |! |! |! |! |! |! |! |! |! |!
sources of referral to a home care agency are family members, nurses,
|! |! |! |! |! |! |! |! |! |! |! |!
physicians, social workers, discharge planners or therapists. |! |! |! |! |! |!
Which of the following is the normal serum electrolyte level for magnesium?
|! |! |! |! |! |! |! |! |! |! |! |!
- Correct answer ✔Correct answer: 1.6 to 2.4 mEq/L
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The school nurse is approached by a mother who explains that her
|! |! |! |! |! |! |! |! |! |! |! |!
kindergarten child is constantly scratching the perianal area and that the area |! |! |! |! |! |! |! |! |! |! |!
is irritated. The RN understands that she should instruct the mother to
|! |! |! |! |! |! |! |! |! |! |! |! |!
obtain a rectal specimen by a tape test and that the mother should obtain the
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
specimen when? - Correct answer ✔The Correct answer is: in the morning,
|! |! |! |! |! |! |! |! |! |! |! |!
when the child awakens Visualization of pinworms by means of a tape test is
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
necessary for the diagnosis. Transparent tape is lightly touched to the anus
|! |! |! |! |! |! |! |! |! |! |! |!
and then applied to a slide for microscopic examination. The best specimen is
|! |! |! |! |! |! |! |! |! |! |! |!
obtained as the child awakens, before toileting or bathing.
|! |! |! |! |! |! |! |! |!
A 20-year-old patient is admitted to the hospital with respiratory failure. He's
|! |! |! |! |! |! |! |! |! |! |! |!
intubated, given oxygen, and is coughing with copious secretions in his lungs.
|! |! |! |! |! |! |! |! |! |! |!
What should be done first? - Correct answer ✔Correct Answer: Suction the
|! |! |! |! |! |! |! |! |! |! |! |! |!
lungs
, The first priority is to make sure the client's airways are clear and that he can
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
breathe. The other choices can be addressed after ensuring the client can
|! |! |! |! |! |! |! |! |! |! |! |! |!
breathe.
A high school student is referred to the school nurse for suspected substance
|! |! |! |! |! |! |! |! |! |! |! |! |!
abuse. Following the nurse's assessment and intervention, what would be the
|! |! |! |! |! |! |! |! |! |! |!
MOST desirable outcome? - Correct answer ✔Correct Answer: The student
|! |! |! |! |! |! |! |! |! |!
accepts a referral to a substance abuse counselor. All of the outcomes stated
|! |! |! |! |! |! |! |! |! |! |! |! |!
are desirable; however, the best outcome is that the student would agree to
|! |! |! |! |! |! |! |! |! |! |! |! |!
seek the assistance of a professional substance abuse counselor.
|! |! |! |! |! |! |! |!
The RN is preparing an intravenous infusion of phenytoin (Dilantin) as
|! |! |! |! |! |! |! |! |! |! |!
prescribed by the physician for the client with seizures. Which of the |! |! |! |! |! |! |! |! |! |! |! |!
following solutions will the nurse use to dilute this medication? - Correct
|! |! |! |! |! |! |! |! |! |! |! |!
answer ✔Normal saline (0.9%) solution. Phenytoin (Dilantin) should be
|! |! |! |! |! |! |! |! |!
administered by injection into a large vein by intermittent intravenous |! |! |! |! |! |! |! |! |! |!
infusion. Normal saline (0.9%) solution is the preferred solution. Dextrose
|! |! |! |! |! |! |! |! |! |!
should be avoided because of medication precipitation.
|! |! |! |! |! |!
Which of the following terms corresponds with the phrase: a woman that is
|! |! |! |! |! |! |! |! |! |! |! |! |!
pregnant? - Correct answer ✔Gravida |! |! |! |!
Gravida is another word for pregnancy. Spermatogonia refers to male sperm
|! |! |! |! |! |! |! |! |! |! |!
cells. Placenta previa is when the placenta is too close to the cervix.
|! |! |! |! |! |! |! |! |! |! |! |!
A healthy first time pregnant client asks the nurse, "How long will I stay in
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
the hospital after my baby is born." The client is scheduled for a Caesarean
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
section. The nurse understands the average timeframe for the hospital stay
|! |! |! |! |! |! |! |! |! |! |!
for a Caesarean section is what? - Correct answer ✔Correct Answer: 72
|! |! |! |! |! |! |! |! |! |! |! |!
DETAILED ANSWERS |!
To evaluate a client's reason for seeking care, the nurse performs deep
|! |! |! |! |! |! |! |! |! |! |! |!
palpation. The purpose of deep palpation is to assess which of the following?
|! |! |! |! |! |! |! |! |! |! |! |! |!
- Correct answer ✔Correct Answer: Organs
|! |! |! |! |!
The purpose of deep palpation, in which the nurse indents the client's skin
|! |! |! |! |! |! |! |! |! |! |! |! |!
approximately 1-1/2", is to assess underlying organs and structures such as |! |! |! |! |! |! |! |! |! |! |!
the kidneys and spleen. Skin turgor, hydration, and temperature can be
|! |! |! |! |! |! |! |! |! |! |!
assessed using light touch or light palpation.
|! |! |! |! |! |!
A client is brought to the emergency department and the physician
|! |! |! |! |! |! |! |! |! |! |!
determines he has gastrointestinal (GI) bleeding. In planning for his care,
|! |! |! |! |! |! |! |! |! |! |!
which of the following would be first priority? - Correct answer ✔The Correct
|! |! |! |! |! |! |! |! |! |! |! |!
answer is: assessment of vital signs Vital sign assessment would be the
|! |! |! |! |! |! |! |! |! |! |! |! |!
priority nursing intervention. This would provide an indication of the amount
|! |! |! |! |! |! |! |! |! |!
of blood loss that has occurred and also provide a baseline by which to
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
monitor the progress of treatment. The other answers (b, c, and d) are
|! |! |! |! |! |! |! |! |! |! |! |! |!
important but not priority actions. |! |! |! |!
When providing instructions to the adolescent regarding physical
|! |! |! |! |! |! |! |!
development of her body, the RN should do all of the following EXCEPT - |! |! |! |! |! |! |! |! |! |! |! |! |! |!
Correct answer ✔Correct Answer: Discuss the importance of avoiding social
|! |! |! |! |! |! |! |! |! |!
events in order to stay out of trouble.
|! |! |! |! |! |! |!
Socialization is very important to teenagers and is a normal part of their |! |! |! |! |! |! |! |! |! |! |! |! |!
development. The other answers (b, c, and d) are all accurate instructions |! |! |! |! |! |! |! |! |! |! |! |!
and discussions for the adolescent regarding development.
|! |! |! |! |! |!
,The nurse is developing discharge plans for a 65-year-old client. The
|! |! |! |! |! |! |! |! |! |! |!
discharge plans indicate the client will be discharged home with home health
|! |! |! |! |! |! |! |! |! |! |!
nursing care. The nurse provides the home health agency with details
|! |! |! |! |! |! |! |! |! |! |! |!
regarding the needs of the patient. The nurse made which of the following to
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
the home health agency? - Correct answer ✔Correct answer: A referral. A
|! |! |! |! |! |! |! |! |! |! |! |!
referral is recommending home care services or giving information to an
|! |! |! |! |! |! |! |! |! |! |!
home care service regarding the client and the client's needs. Typically the
|! |! |! |! |! |! |! |! |! |! |! |!
sources of referral to a home care agency are family members, nurses,
|! |! |! |! |! |! |! |! |! |! |! |!
physicians, social workers, discharge planners or therapists. |! |! |! |! |! |!
Which of the following is the normal serum electrolyte level for magnesium?
|! |! |! |! |! |! |! |! |! |! |! |!
- Correct answer ✔Correct answer: 1.6 to 2.4 mEq/L
|! |! |! |! |! |! |! |!
The school nurse is approached by a mother who explains that her
|! |! |! |! |! |! |! |! |! |! |! |!
kindergarten child is constantly scratching the perianal area and that the area |! |! |! |! |! |! |! |! |! |! |!
is irritated. The RN understands that she should instruct the mother to
|! |! |! |! |! |! |! |! |! |! |! |! |!
obtain a rectal specimen by a tape test and that the mother should obtain the
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
specimen when? - Correct answer ✔The Correct answer is: in the morning,
|! |! |! |! |! |! |! |! |! |! |! |!
when the child awakens Visualization of pinworms by means of a tape test is
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
necessary for the diagnosis. Transparent tape is lightly touched to the anus
|! |! |! |! |! |! |! |! |! |! |! |!
and then applied to a slide for microscopic examination. The best specimen is
|! |! |! |! |! |! |! |! |! |! |! |!
obtained as the child awakens, before toileting or bathing.
|! |! |! |! |! |! |! |! |!
A 20-year-old patient is admitted to the hospital with respiratory failure. He's
|! |! |! |! |! |! |! |! |! |! |! |!
intubated, given oxygen, and is coughing with copious secretions in his lungs.
|! |! |! |! |! |! |! |! |! |! |!
What should be done first? - Correct answer ✔Correct Answer: Suction the
|! |! |! |! |! |! |! |! |! |! |! |! |!
lungs
, The first priority is to make sure the client's airways are clear and that he can
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
breathe. The other choices can be addressed after ensuring the client can
|! |! |! |! |! |! |! |! |! |! |! |! |!
breathe.
A high school student is referred to the school nurse for suspected substance
|! |! |! |! |! |! |! |! |! |! |! |! |!
abuse. Following the nurse's assessment and intervention, what would be the
|! |! |! |! |! |! |! |! |! |! |!
MOST desirable outcome? - Correct answer ✔Correct Answer: The student
|! |! |! |! |! |! |! |! |! |!
accepts a referral to a substance abuse counselor. All of the outcomes stated
|! |! |! |! |! |! |! |! |! |! |! |! |!
are desirable; however, the best outcome is that the student would agree to
|! |! |! |! |! |! |! |! |! |! |! |! |!
seek the assistance of a professional substance abuse counselor.
|! |! |! |! |! |! |! |!
The RN is preparing an intravenous infusion of phenytoin (Dilantin) as
|! |! |! |! |! |! |! |! |! |! |!
prescribed by the physician for the client with seizures. Which of the |! |! |! |! |! |! |! |! |! |! |! |!
following solutions will the nurse use to dilute this medication? - Correct
|! |! |! |! |! |! |! |! |! |! |! |!
answer ✔Normal saline (0.9%) solution. Phenytoin (Dilantin) should be
|! |! |! |! |! |! |! |! |!
administered by injection into a large vein by intermittent intravenous |! |! |! |! |! |! |! |! |! |!
infusion. Normal saline (0.9%) solution is the preferred solution. Dextrose
|! |! |! |! |! |! |! |! |! |!
should be avoided because of medication precipitation.
|! |! |! |! |! |!
Which of the following terms corresponds with the phrase: a woman that is
|! |! |! |! |! |! |! |! |! |! |! |! |!
pregnant? - Correct answer ✔Gravida |! |! |! |!
Gravida is another word for pregnancy. Spermatogonia refers to male sperm
|! |! |! |! |! |! |! |! |! |! |!
cells. Placenta previa is when the placenta is too close to the cervix.
|! |! |! |! |! |! |! |! |! |! |! |!
A healthy first time pregnant client asks the nurse, "How long will I stay in
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
the hospital after my baby is born." The client is scheduled for a Caesarean
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
section. The nurse understands the average timeframe for the hospital stay
|! |! |! |! |! |! |! |! |! |! |!
for a Caesarean section is what? - Correct answer ✔Correct Answer: 72
|! |! |! |! |! |! |! |! |! |! |! |!
