NACE Foundations of Nursing Practice 5 — Questions and Answers
Question 1: A nurse is preparing to insert a urinary catheter. Which action is essential to maintain sterile technique?
- Open the sterile field after donning non-sterile gloves
- Place sterile items on the sterile field before gloving
- Re-touch the catheter tip if it contacts the client's skin
- Keep sterile gloved hands above waist level at all times (Correct answer)
Correct answer: Keep sterile gloved hands above waist level at all times
Sterile gloved hands must remain above waist level and within the nurse's field of vision to be considered sterile.
Question 2: A client's morning blood glucose is 52 mg/dL and they are conscious and able to swallow. What is the nurse's first action?
- Administer 50% dextrose IV push
- Give 15–20 grams of fast-acting carbohydrates orally (Correct answer)
- Notify the physician immediately before intervening
- Hold the morning insulin and reassess in one hour
Correct answer: Give 15–20 grams of fast-acting carbohydrates orally
The '15-15 rule' directs the nurse to give 15–20 g of fast-acting carbohydrates orally to a conscious hypoglycemic client first.
Question 3: Which client statement indicates a correct understanding of incentive spirometry after abdominal surgery?
- 'I should use it only when I feel short of breath.'
- 'I will take a slow deep breath in and hold it for 3–5 seconds.' (Correct answer)
- 'I should blow out as hard as I can into the device.'
- 'I only need to use it once in the morning.'
Correct answer: 'I will take a slow deep breath in and hold it for 3–5 seconds.'
Correct incentive spirometry technique involves a slow maximal inhalation followed by a 3–5 second breath-hold to open alveoli.
Question 4: A nurse applies a wet-to-dry dressing to a wound. What is the primary purpose of this dressing type?
- Provide a moist wound environment to promote granulation
- Mechanically debride necrotic tissue as the dressing dries (Correct answer)
- Protect the wound from contamination with a moisture barrier
- Deliver topical antibiotics directly to the wound bed
Correct answer: Mechanically debride necrotic tissue as the dressing dries
Wet-to-dry dressings adhere to necrotic debris when wet, and removal of the dry dressing mechanically debrides the wound.
Question 5: A client's urine output for the past 8 hours totals 200 mL. How should the nurse document this finding?
- Polyuria
- Oliguria (Correct answer)
- Anuria
- Nocturia
Correct answer: Oliguria
Oliguria is defined as urine output less than 30 mL/hour or less than 400 mL/day; 200 mL in 8 hours (25 mL/hr) meets this criterion.
Question 6: When teaching a client about a low-sodium diet, which food choice indicates the client needs further instruction?
- Fresh baked chicken breast
- Canned tomato soup (Correct answer)
- Fresh steamed broccoli
- Apple slices with peanut butter
Correct answer: Canned tomato soup
Canned soups are typically very high in sodium and are not appropriate for a low-sodium diet.
Question 7: A nurse receives a telephone order from a physician. Which step is most important to ensure accuracy?
- Ask a second nurse to listen on another phone
- Read the order back to the physician and receive confirmation (Correct answer)
- Write the order and have the physician sign it within 72 hours
- Enter the verbal order directly into the electronic health record
Correct answer: Read the order back to the physician and receive confirmation
Read-back verification — repeating the order to the prescriber and receiving confirmation — is the required safety step for telephone orders.
NACE Foundations of Nursing Practice 5
A nurse is preparing to insert a urinary catheter.
Which action is essential to maintain sterile technique?