NLN NACE Prep
A nurse is caring for a client that has not voided for several hours. When percussing the client's bladder
to assess for distention, the nurse should expect to hear...... - ANSDullness
This indicates a full bladder
-Tympany means empty
-Hyperrenosance is an abnormal pulmonary sound
-Renosance is a vibration
A client is receiving intermittent nasogastric tube feedings. A nurse should aspirate the residual stomach
contents prior to administering a scheduled feeding to..... - ANSDetermine absorption of feedings
Which medication should be delivered using the z-track method? - ANSIron dextran(Imferon) to prevent
tissue damage
A nurse is to administer medication to 2 clients sitting in the lounge with several other clients. What
action by the nurse is appropriate? - ANSCheck name bands on the clients' arms
A client is to be checked for residual urine. At which time should the procedure be performed? -
ANSImmediately after the client voids
A nurse is to obtain a residual urine specimen from an elderly client whose indwelling foley catheter was
just removed. What is the purpose of a residual urine specimen? - ANSTo assess for urinary retention
A nurse is caring for a client receiving intravenous therapy. What would indicate to the nurse that the
intravenous infusion has infiltrated? - ANSCutaneous tissue at the intravenous site is swollen
-the IV catheter should be removed and a new site should be restarted
Which of the following measures should a nurse include in the plan of care of a patient with
hyperthyroidism? - ANSKeeping the client's environment cool
,-A client with hyperthyroidism is heat intolerant
-The client should be encouraged to eat foods high in calories because they are often below their ideal
weight and have difficulty maintaining a healthy weight
A nurse should reinforce the instructions to the family of a client who has propulsive gait related to
Parkinsons Disease? - ANSKeep the floor of the client's surroundings free of obstacles
-Propulsive gait is a stooping, rigid posture with the head and neck bent forward. Steps tend to become
faster and shorter.
-Encourage the client to ambulate as much as they want in order to maintain activity level
Which of these measures should a nurse emphasize when feeding a client with left side facial paralysis
who has difficulty swallowing? - ANSPlacing the food on the unaffected side of the client's mouth
-prevents aspiration
Before assisting a patient who is on day postop OOB for the first time, a nurse should take which action?
- ANSAssess pulse and blood pressure in order to assess the client for orthostatic hypotension
Which of these objectives is most important to include in the care of a client with multiple sclerosis? -
ANSPrevent contractures
-it will decrease the client's functional abilities
A client who is terminally ill with AIDS is admitted to the hospital. What precaution should be included in
the client's plan of care? - ANSStandard Precautions
A nurse is caring for a client who had a right lower lobectomy and has a closed water-sealed chest
drainage system in place. Which action should the nurse include as part of the plan of care? - ANSKeep
the system below the level of the client's waist
-prevents backflow of fluids
A client who is suspected of having a hiatal hernia is admitted to the hospital. Which question is
important for the nurse to ask? - ANS"Do you experience heartburn after a large meal?"
-They need to eat small, frequent meals
, A nurse discovers flames in a wastebasket in the room of a client who is a paraplegic. What action should
the nurse take first? - ANSRescue the client
A nurse is caring for a client whose arms are in restraints. When is it essential for the nurse to remove
the restraints? - ANSEvery 2hours to check circulation
-Manual restraints can decrease circulation
A nurse is instructing an adult client on the correct technique for ear drop instillation. What action by the
client indicates the need for further teaching? - ANSThe client pulls the ear lobe down and back when
administering the ear drops
-Ages 3 and up should be pulled up and outward
A nurse obtains lab results for a client prior to surgery. What should the nurse report to the physician? -
ANSProthrombin time of 32 seconds
-May be indicative of bleeding/clotting problems
-Normal is 11-15 seconds
A client has ingested a toxic dose of acetaminophen. A nurse should expect alteration in what lab values?
- ANSSerum bilirubin
-Tylenol can cause liver failure
An 83 year old client was recently admitted to a nursing care facility frequently looks vacantly at family
members and says, "I don't know where I am." A nurse notes that the client also has a history of getting
up several times at night and falling. Based on this information the nurse should place priority on which
measure? - ANSMaintaining the bed in a low position
What situation can a nurse be held negligent? - ANSThe nurse reports a client's toxic reaction to a drug
but fails to report it to the physician
-Negligence is a failure to comply with the applicable standard of care
When a client dies in the hospital what is the most important measure that a nurse should take? -
ANSPlacing identification tags on the body
A nurse is caring for a client that has not voided for several hours. When percussing the client's bladder
to assess for distention, the nurse should expect to hear...... - ANSDullness
This indicates a full bladder
-Tympany means empty
-Hyperrenosance is an abnormal pulmonary sound
-Renosance is a vibration
A client is receiving intermittent nasogastric tube feedings. A nurse should aspirate the residual stomach
contents prior to administering a scheduled feeding to..... - ANSDetermine absorption of feedings
Which medication should be delivered using the z-track method? - ANSIron dextran(Imferon) to prevent
tissue damage
A nurse is to administer medication to 2 clients sitting in the lounge with several other clients. What
action by the nurse is appropriate? - ANSCheck name bands on the clients' arms
A client is to be checked for residual urine. At which time should the procedure be performed? -
ANSImmediately after the client voids
A nurse is to obtain a residual urine specimen from an elderly client whose indwelling foley catheter was
just removed. What is the purpose of a residual urine specimen? - ANSTo assess for urinary retention
A nurse is caring for a client receiving intravenous therapy. What would indicate to the nurse that the
intravenous infusion has infiltrated? - ANSCutaneous tissue at the intravenous site is swollen
-the IV catheter should be removed and a new site should be restarted
Which of the following measures should a nurse include in the plan of care of a patient with
hyperthyroidism? - ANSKeeping the client's environment cool
,-A client with hyperthyroidism is heat intolerant
-The client should be encouraged to eat foods high in calories because they are often below their ideal
weight and have difficulty maintaining a healthy weight
A nurse should reinforce the instructions to the family of a client who has propulsive gait related to
Parkinsons Disease? - ANSKeep the floor of the client's surroundings free of obstacles
-Propulsive gait is a stooping, rigid posture with the head and neck bent forward. Steps tend to become
faster and shorter.
-Encourage the client to ambulate as much as they want in order to maintain activity level
Which of these measures should a nurse emphasize when feeding a client with left side facial paralysis
who has difficulty swallowing? - ANSPlacing the food on the unaffected side of the client's mouth
-prevents aspiration
Before assisting a patient who is on day postop OOB for the first time, a nurse should take which action?
- ANSAssess pulse and blood pressure in order to assess the client for orthostatic hypotension
Which of these objectives is most important to include in the care of a client with multiple sclerosis? -
ANSPrevent contractures
-it will decrease the client's functional abilities
A client who is terminally ill with AIDS is admitted to the hospital. What precaution should be included in
the client's plan of care? - ANSStandard Precautions
A nurse is caring for a client who had a right lower lobectomy and has a closed water-sealed chest
drainage system in place. Which action should the nurse include as part of the plan of care? - ANSKeep
the system below the level of the client's waist
-prevents backflow of fluids
A client who is suspected of having a hiatal hernia is admitted to the hospital. Which question is
important for the nurse to ask? - ANS"Do you experience heartburn after a large meal?"
-They need to eat small, frequent meals
, A nurse discovers flames in a wastebasket in the room of a client who is a paraplegic. What action should
the nurse take first? - ANSRescue the client
A nurse is caring for a client whose arms are in restraints. When is it essential for the nurse to remove
the restraints? - ANSEvery 2hours to check circulation
-Manual restraints can decrease circulation
A nurse is instructing an adult client on the correct technique for ear drop instillation. What action by the
client indicates the need for further teaching? - ANSThe client pulls the ear lobe down and back when
administering the ear drops
-Ages 3 and up should be pulled up and outward
A nurse obtains lab results for a client prior to surgery. What should the nurse report to the physician? -
ANSProthrombin time of 32 seconds
-May be indicative of bleeding/clotting problems
-Normal is 11-15 seconds
A client has ingested a toxic dose of acetaminophen. A nurse should expect alteration in what lab values?
- ANSSerum bilirubin
-Tylenol can cause liver failure
An 83 year old client was recently admitted to a nursing care facility frequently looks vacantly at family
members and says, "I don't know where I am." A nurse notes that the client also has a history of getting
up several times at night and falling. Based on this information the nurse should place priority on which
measure? - ANSMaintaining the bed in a low position
What situation can a nurse be held negligent? - ANSThe nurse reports a client's toxic reaction to a drug
but fails to report it to the physician
-Negligence is a failure to comply with the applicable standard of care
When a client dies in the hospital what is the most important measure that a nurse should take? -
ANSPlacing identification tags on the body
