NACE Foundations of Nursing Practice 4 — Questions and Answers
Question 1: A nurse is caring for a client who refuses a prescribed blood transfusion for religious reasons. Which action best reflects the ethical principle of autonomy?
- Administer the transfusion because it is life-saving
- Document the refusal and notify the physician without proceeding (Correct answer)
- Consult the ethics committee to override the client's decision
- Ask the family to convince the client to accept treatment
Correct answer: Document the refusal and notify the physician without proceeding
Autonomy requires respecting a competent client's right to refuse treatment; the nurse documents the refusal and informs the provider.
Question 2: Which position is most appropriate for a client experiencing respiratory distress to maximize lung expansion?
- Supine with legs elevated
- High Fowler's (90 degrees) (Correct answer)
- Trendelenburg
- Left lateral Sims'
Correct answer: High Fowler's (90 degrees)
High Fowler's position uses gravity to lower abdominal organs and allows maximum diaphragmatic excursion and lung expansion.
Question 3: A nurse notes a discrepancy between the medication administration record (MAR) and the number of controlled substance tablets remaining. What is the priority action?
- Administer the medication and recount later
- Report the discrepancy to the charge nurse immediately (Correct answer)
- Document the error without notifying anyone
- Assume a counting error occurred and adjust the count
Correct answer: Report the discrepancy to the charge nurse immediately
A controlled substance discrepancy must be reported immediately to the charge nurse and investigated per institutional policy.
Question 4: Which laboratory value indicates that a client receiving heparin therapy is within the therapeutic range?
- aPTT 25 seconds (normal 25-35 sec)
- aPTT 60 seconds (1.5-2.5x control) (Correct answer)
- INR 3.5
- Platelet count 50,000/mm³
Correct answer: aPTT 60 seconds (1.5-2.5x control)
Therapeutic heparin effect is reflected by an aPTT of 1.5–2.5 times the control (approximately 60–80 seconds).
Question 5: A client is admitted with a stage III pressure injury to the sacrum. Which intervention has the highest priority?
- Massage the reddened area to improve circulation
- Reposition the client every 2 hours (Correct answer)
- Apply a dry gauze dressing to the wound
- Restrict the client's fluid intake
Correct answer: Reposition the client every 2 hours
Turning and repositioning every 2 hours is the primary prevention and treatment intervention to relieve pressure and promote healing.
Question 6: A nurse uses the SBAR communication technique when calling a physician. Which component is 'A' in SBAR?
- Assessment of the client's current condition (Correct answer)
- Allergies the client has reported
- Actions already taken by the nurse
- Anticipated orders from the physician
Correct answer: Assessment of the client's current condition
In SBAR, 'A' stands for Assessment, which is the nurse's clinical interpretation of the situation.
Question 7: Which nursing action is the single most effective method for preventing the transmission of healthcare-associated infections?
- Wearing sterile gloves for all patient contact
- Performing proper hand hygiene before and after client care (Correct answer)
- Placing all clients in contact precautions
- Using N95 respirators during routine care
Correct answer: Performing proper hand hygiene before and after client care
Hand hygiene is consistently identified as the most effective measure to prevent the spread of healthcare-associated infections.
NACE Foundations of Nursing Practice 4
A nurse is caring for a client who refuses a prescribed blood transfusion for religious reasons.
Which action best reflects the ethical principle of autonomy?