NACE CP2 EXAM – CLINICAL PRACTICE II
EXAM ACTUAL PREP QUESTIONS AND WELL
REVISED ANSWERS - LATEST AND COMPLETE
UPDATE WITH VERIFIED SOLUTIONS –
ASSURED PASS
1. A patient with acute shortness of breath, tachycardia, and unilateral chest pain
following prolonged immobilization is admitted. Which initial nursing action is the
priority?
A. Administer prescribed analgesics
B. Encourage deep breathing exercises
C. Assess oxygen saturation and initiate oxygen therapy as indicated
D. Prepare the patient for discharge education
Rationale: These symptoms suggest possible pulmonary embolism. Immediate
assessment and support of oxygenation take priority to prevent hypoxia and
deterioration.
2. When administering intravenous potassium chloride, which practice is most
appropriate?
A. Administer as a rapid IV push
B. Dilute in minimal fluid to reduce volume overload
C. Use an infusion pump and monitor cardiac rhythm
D. Administer intramuscularly if IV access is difficult
Rationale: Potassium can cause fatal arrhythmias if infused too rapidly;
controlled infusion and cardiac monitoring are required.
3. A nurse identifies that a colleague administered the wrong dose of medication.
What is the most ethically appropriate action?
,A. Ignore the error if no harm occurred
B. Confront the colleague privately and take no further action
C. Report the incident according to institutional policy
D. Document the error in personal notes only
Rationale: Professional ethics and patient safety standards require transparent
reporting of errors to prevent harm and promote accountability.
4. Which laboratory finding is most indicative of acute kidney injury?
A. Decreased hemoglobin
B. Elevated serum sodium
C. Rising serum creatinine
D. Low serum calcium
Rationale: Serum creatinine is a key indicator of renal filtration function and
rises with kidney injury.
5. A patient refuses a life-saving blood transfusion for religious reasons. What
should the nurse do first?
A. Notify hospital administration immediately
B. Attempt to persuade the patient to consent
C. Verify the patient’s decision-making capacity
D. Proceed with treatment in the patient’s best interest
Rationale: Respect for autonomy requires confirmation that the patient is
competent to make informed decisions.
6. Which intervention best prevents hospital-acquired pressure injuries?
A. Limiting patient mobility
B. Using donut-shaped cushions
C. Regular repositioning and skin assessment
,D. Applying antiseptic solutions daily
Rationale: Pressure relief and early detection are evidence-based strategies for
preventing pressure injuries.
7. During handover, which information is most critical to communicate?
A. Patient’s family concerns
B. Physician’s personality
C. Recent changes in patient condition
D. Room assignment
Rationale: Continuity of care depends on accurate communication of clinical
changes.
8. Which sign most strongly suggests hypoglycemia in a diabetic patient?
A. Warm, dry skin
B. Bradycardia
C. Diaphoresis and confusion
D. Hypertension
Rationale: Neurogenic and neuroglycopenic symptoms are hallmark signs of
hypoglycemia.
9. A patient on anticoagulant therapy develops hematuria. What is the nurse’s
priority?
A. Increase fluid intake
B. Document and monitor only
C. Notify the prescribing provider immediately
D. Discontinue medication independently
Rationale: Hematuria may indicate excessive anticoagulation and requires
prompt medical evaluation.
, 10. Which action best supports infection control in a clinical setting?
A. Wearing gloves for all patient contact
B. Performing hand hygiene before and after patient contact
C. Using antibiotics prophylactically
D. Isolating all patients with fever
Rationale: Hand hygiene is the single most effective measure to prevent
healthcare-associated infections.
11. Informed consent requires that the patient:
A. Signs the consent form
B. Receives information from the nurse
C. Understands the risks, benefits, and alternatives
D. Agrees with the physician’s recommendation
Rationale: Understanding is a core legal and ethical requirement of valid
informed consent.
12. A patient suddenly becomes unresponsive. What is the nurse’s first action?
A. Call the family
B. Document the event
C. Assess airway, breathing, and circulation
D. Obtain vital signs
Rationale: Primary survey (ABC) guides immediate life-saving interventions.
13. Which electrolyte imbalance is most likely to cause cardiac arrhythmias?
A. Hyponatremia
B. Hypercalcemia
C. Hyperkalemia
EXAM ACTUAL PREP QUESTIONS AND WELL
REVISED ANSWERS - LATEST AND COMPLETE
UPDATE WITH VERIFIED SOLUTIONS –
ASSURED PASS
1. A patient with acute shortness of breath, tachycardia, and unilateral chest pain
following prolonged immobilization is admitted. Which initial nursing action is the
priority?
A. Administer prescribed analgesics
B. Encourage deep breathing exercises
C. Assess oxygen saturation and initiate oxygen therapy as indicated
D. Prepare the patient for discharge education
Rationale: These symptoms suggest possible pulmonary embolism. Immediate
assessment and support of oxygenation take priority to prevent hypoxia and
deterioration.
2. When administering intravenous potassium chloride, which practice is most
appropriate?
A. Administer as a rapid IV push
B. Dilute in minimal fluid to reduce volume overload
C. Use an infusion pump and monitor cardiac rhythm
D. Administer intramuscularly if IV access is difficult
Rationale: Potassium can cause fatal arrhythmias if infused too rapidly;
controlled infusion and cardiac monitoring are required.
3. A nurse identifies that a colleague administered the wrong dose of medication.
What is the most ethically appropriate action?
,A. Ignore the error if no harm occurred
B. Confront the colleague privately and take no further action
C. Report the incident according to institutional policy
D. Document the error in personal notes only
Rationale: Professional ethics and patient safety standards require transparent
reporting of errors to prevent harm and promote accountability.
4. Which laboratory finding is most indicative of acute kidney injury?
A. Decreased hemoglobin
B. Elevated serum sodium
C. Rising serum creatinine
D. Low serum calcium
Rationale: Serum creatinine is a key indicator of renal filtration function and
rises with kidney injury.
5. A patient refuses a life-saving blood transfusion for religious reasons. What
should the nurse do first?
A. Notify hospital administration immediately
B. Attempt to persuade the patient to consent
C. Verify the patient’s decision-making capacity
D. Proceed with treatment in the patient’s best interest
Rationale: Respect for autonomy requires confirmation that the patient is
competent to make informed decisions.
6. Which intervention best prevents hospital-acquired pressure injuries?
A. Limiting patient mobility
B. Using donut-shaped cushions
C. Regular repositioning and skin assessment
,D. Applying antiseptic solutions daily
Rationale: Pressure relief and early detection are evidence-based strategies for
preventing pressure injuries.
7. During handover, which information is most critical to communicate?
A. Patient’s family concerns
B. Physician’s personality
C. Recent changes in patient condition
D. Room assignment
Rationale: Continuity of care depends on accurate communication of clinical
changes.
8. Which sign most strongly suggests hypoglycemia in a diabetic patient?
A. Warm, dry skin
B. Bradycardia
C. Diaphoresis and confusion
D. Hypertension
Rationale: Neurogenic and neuroglycopenic symptoms are hallmark signs of
hypoglycemia.
9. A patient on anticoagulant therapy develops hematuria. What is the nurse’s
priority?
A. Increase fluid intake
B. Document and monitor only
C. Notify the prescribing provider immediately
D. Discontinue medication independently
Rationale: Hematuria may indicate excessive anticoagulation and requires
prompt medical evaluation.
, 10. Which action best supports infection control in a clinical setting?
A. Wearing gloves for all patient contact
B. Performing hand hygiene before and after patient contact
C. Using antibiotics prophylactically
D. Isolating all patients with fever
Rationale: Hand hygiene is the single most effective measure to prevent
healthcare-associated infections.
11. Informed consent requires that the patient:
A. Signs the consent form
B. Receives information from the nurse
C. Understands the risks, benefits, and alternatives
D. Agrees with the physician’s recommendation
Rationale: Understanding is a core legal and ethical requirement of valid
informed consent.
12. A patient suddenly becomes unresponsive. What is the nurse’s first action?
A. Call the family
B. Document the event
C. Assess airway, breathing, and circulation
D. Obtain vital signs
Rationale: Primary survey (ABC) guides immediate life-saving interventions.
13. Which electrolyte imbalance is most likely to cause cardiac arrhythmias?
A. Hyponatremia
B. Hypercalcemia
C. Hyperkalemia
