NACE EXAM
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1. 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.: dullness
2. 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.: The nurse
spills sterile saline on the sterile field.
3. 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.: Run the tap water while
the client is on the toilet.
4. 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.: Giving the client sponge baths
with tepid water several times a day.
5. 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.: mask
, NACE EXAM
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6. 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.: corn oil
7. 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.: Recheck the temperature with another
thermometer
8. 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.: implementing
9. 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.: personal attitudes about sexuality
10. A nurse is caring for a client whose laboratory reports indicate hyperna-
tremia. 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.: increasing fluid intake
11. 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
, NACE EXAM
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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
-"Ask, "Why are you behaving in this hostile manner?": Say nothing more until
the client makes a verbal response
12. A nurse prepares to teach a client how to self-administer injections. The
nurse has planned to teach the client about the medication during this ses-
sion. The client says repeatedly, "You mean I have to stick myself with a
needle?" Which of these responses would be most supportive of the learning
process?
-I see that you're upset, but let's start by discussing what the drug can do for
you
-Many people have this same concern, but it won't be as hard as you expect
-You're bothered by the thought of injecting yourself
-I wonder if you're reacting to the feelings that people have about illegal drug
use.: You're bothered by the thought of injecting yourself
13. A client has an order for psyllium hydrophilic mucilloid (Metamucil) 1
packet po qd. Which of these actions is essential when a nurse is preparing
to administer this medication?
-Prepare the medication with four ounces of juice
-Provide special mouth care after medication administration.
-Administer the medication after it stops effervescing.
-Monitor bowel sounds before administration.: Monitor bowel sounds before
administration.
14. A client who is three days postoperative is refusing to deep breathe and
cough because of incisional discomfort. Which of these nursing diagnoses
should receive priority in this client's care plan?
-Noncompliance
-Impaired gas exchange.
-Impaired physical mobility.
-Pain.: pain
15. While preparing a client for surgery, a nurse discovers that the client does
not understand the surgical procedure. A signed surgical consent is on the
chart. Which of these actions should the nurse take?
-Reassure the client.
-Send the client to surgery.
-Explain the operative procedure.
-Notify the physician: notify the physician
Study online at https://quizlet.com/_bv0ifv
1. 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.: dullness
2. 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.: The nurse
spills sterile saline on the sterile field.
3. 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.: Run the tap water while
the client is on the toilet.
4. 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.: Giving the client sponge baths
with tepid water several times a day.
5. 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.: mask
, NACE EXAM
Study online at https://quizlet.com/_bv0ifv
6. 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.: corn oil
7. 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.: Recheck the temperature with another
thermometer
8. 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.: implementing
9. 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.: personal attitudes about sexuality
10. A nurse is caring for a client whose laboratory reports indicate hyperna-
tremia. 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.: increasing fluid intake
11. 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
, NACE EXAM
Study online at https://quizlet.com/_bv0ifv
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
-"Ask, "Why are you behaving in this hostile manner?": Say nothing more until
the client makes a verbal response
12. A nurse prepares to teach a client how to self-administer injections. The
nurse has planned to teach the client about the medication during this ses-
sion. The client says repeatedly, "You mean I have to stick myself with a
needle?" Which of these responses would be most supportive of the learning
process?
-I see that you're upset, but let's start by discussing what the drug can do for
you
-Many people have this same concern, but it won't be as hard as you expect
-You're bothered by the thought of injecting yourself
-I wonder if you're reacting to the feelings that people have about illegal drug
use.: You're bothered by the thought of injecting yourself
13. A client has an order for psyllium hydrophilic mucilloid (Metamucil) 1
packet po qd. Which of these actions is essential when a nurse is preparing
to administer this medication?
-Prepare the medication with four ounces of juice
-Provide special mouth care after medication administration.
-Administer the medication after it stops effervescing.
-Monitor bowel sounds before administration.: Monitor bowel sounds before
administration.
14. A client who is three days postoperative is refusing to deep breathe and
cough because of incisional discomfort. Which of these nursing diagnoses
should receive priority in this client's care plan?
-Noncompliance
-Impaired gas exchange.
-Impaired physical mobility.
-Pain.: pain
15. While preparing a client for surgery, a nurse discovers that the client does
not understand the surgical procedure. A signed surgical consent is on the
chart. Which of these actions should the nurse take?
-Reassure the client.
-Send the client to surgery.
-Explain the operative procedure.
-Notify the physician: notify the physician
