NACE Foundations of Nursing Practice 2 — Questions and Answers
Question 1: Which vital sign change should the nurse report immediately to the healthcare provider?
- Oral temperature of 99.0 degrees Fahrenheit
- Blood pressure of 88/52 mmHg (Correct answer)
- Pulse rate of 78 beats per minute
- Respiratory rate of 16 breaths per minute
Correct answer: Blood pressure of 88/52 mmHg
A blood pressure of 88/52 mmHg indicates hypotension that could signify shock, hemorrhage, or cardiovascular compromise and requires immediate medical attention.
Normal adult blood pressure ranges from 90/60 to 120/80 mmHg. A reading of 88/52 mmHg represents hypotension that may indicate hypovolemic shock, sepsis, cardiac failure, or medication side effects.
Question 2: A nurse is preparing to administer an intramuscular injection to an adult. Which site accommodates the largest volume of medication?
- Deltoid muscle
- Vastus lateralis
- Ventrogluteal site (Correct answer)
- Dorsogluteal site
Correct answer: Ventrogluteal site
The ventrogluteal site is the preferred and largest IM injection site for adults, accommodating up to 3 mL and having the least risk of injury to nerves and blood vessels.
The ventrogluteal site (gluteus medius and minimus muscles) is recommended by the CDC and WHO as the preferred site for IM injections in adults. It accommodates up to 3 mL of medication, has a thick muscle mass with minimal subcutaneous fat, and is distant from major nerves and blood vessels.
Question 3: When measuring a patient's blood pressure, the nurse obtains a reading during the first Korotkoff sound. This represents which value?
- Diastolic pressure
- Systolic pressure (Correct answer)
- Mean arterial pressure
- Pulse pressure
Correct answer: Systolic pressure
The first Korotkoff sound, heard as a clear tapping, represents the systolic blood pressure, the pressure when the heart ventricles contract.
Korotkoff sounds are the auditory indicators used during manual blood pressure measurement. Phase I (first sound) is a clear, rhythmic tapping that marks the systolic pressure, the point where blood flow first passes through the compressed artery.
Question 4: A patient is ordered strict intake and output monitoring. Which item should the nurse include in the output measurement?
- Insensible perspiration
- Emesis (Correct answer)
- Food consumed at meals
- Intravenous fluid rate
Correct answer: Emesis
Emesis (vomit) is a measurable fluid output that must be recorded in strict I&O monitoring to accurately track fluid balance.
Strict I&O monitoring tracks all measurable fluid gains and losses. Output includes: urine, emesis, diarrhea, wound drainage, nasogastric tube output, chest tube drainage, and ostomy output. Insensible losses (perspiration, respiration) are estimated but not directly measured.
Question 5: Which laboratory value requires the nurse to hold the next dose of warfarin and notify the provider?
- INR of 2.5
- INR of 5.8 (Correct answer)
- PT of 14 seconds
- aPTT of 35 seconds
Correct answer: INR of 5.8
An INR of 5.8 is critically elevated (therapeutic range for most conditions is 2.0-3.0), indicating a high risk for hemorrhage and requiring immediate provider notification.
Warfarin's anticoagulant effect is monitored using the International Normalized Ratio (INR). Therapeutic INR for most conditions (DVT, PE, atrial fibrillation) is 2.0-3.0. An INR of 5.8 represents a critical value with significant hemorrhage risk.
Question 6: A nurse is inserting an indwelling urinary catheter in a female patient. During insertion, urine is not obtained. What should the nurse do?
- Inflate the balloon and wait for urine flow
- Remove the catheter and insert it into the correct opening
- Push the catheter in further until urine appears
- Leave the catheter in place and insert a new one into the urethral meatus (Correct answer)
Correct answer: Leave the catheter in place and insert a new one into the urethral meatus
If no urine returns, the catheter was likely inserted into the vagina. The nurse should leave it as a landmark, insert a new sterile catheter into the urethral meatus, then remove the misplaced catheter.
Female catheterization can be challenging due to anatomical proximity of the vaginal and urethral openings. If the catheter enters the vagina (no urine return), the contaminated catheter should be left in place as a visual landmark to help identify the urethral meatus, which is located slightly anterior and superior. A new sterile catheter is then inserted into the correct opening.
NACE Foundations of Nursing Practice 2
Which vital sign change should the nurse report immediately to the healthcare provider?