NACE PN TO RN Exam
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,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: 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?
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: 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: 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: 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?
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: 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.