NACE Exam Latest 2024 Actual Exam: 160 Questions and Answers with Rationales, Exams of Nursing

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NACE EXAM LATEST 2024 ACTUAL EXAM

16 0 QUESTIONS AND CORRECT

DETAILED ANSWERS WITH RATIONALES

(VERIFIED ANSWERS) GRADED A+

A nurse is reinforcing instructions about breast self-examination with a premenopausal woman. Which of these statements, if made by the client, would indicate that she needs FURTHER instructions?

• I will use a circular pattern when feeling for abnormalities of my breasts.
• I will examine both of my breasts weekly while showering.
• I will look in a mirror for changes in contour of my breasts.
• I will gently compress the nipple of my breasts to check for discharge. I will examine both of my breasts weekly while showering. A nurse is reinforcing teaching with a client who is diagnosed with non-insulin-dependent diabetes mellitus. Which of these topics is most important for the nurse to emphasize?
• Individualized prescription of diet, exercise, and medication.
• Clinical manifestations of non-insulin-dependent diabetes.
• Lifestyle modifications to reduce stress.
• Personal hygiene measures. Individualized prescription of diet, exercise, and medication. A nurse should assess a client who has a thyroidectomy for signs of hypocalcemia, which include

• gingival hypertrophy.
• painful joints.
• tetany.
• toothaches. tetany A nurse should expect that a client who has open-angle glaucoma will report
• difficulty seeing distant objects.
• photophobia.
• severe eye pain.
• loss of peripheral vision. loss of peripheral vision A nurse should recognize that a client who has a perineal prostatectomy rather than a transurethral prostatectomy is more likely to develop which of these complications?
• Ureteral stenosis.
• Impotence.
• Renal calculi.
• Glomerulonephritis. impotence (ED) A nurse should teach a client who has diabetes mellitus & their family and friends to recognize early signs of a hypoglycemic reaction, which include
• irritability.
• fruity breath.

• double vision.
• hot, dry skin. irritability A client has an order for 1 gm of medication to be administered intramuscularly. The medication available is labeled 500 mg/mL. How many milliliters should a nurse administer?
• 0.5 mL
• 1.0 mL
• 2.0 mL
• 3.5 mL 2 mL. If 500 mg equals 1 mL, 1000 mg equals 2 mL 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 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. 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. 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.

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 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 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 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 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 A nurse is caring for a client whose laboratory reports indicate hypernatremia. 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 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 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 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 session. 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 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. 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 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

A 31-year-old client is receiving medical treatment for ulcerative colitis. The treatment includes antibiotics and prednisone. A nurse should plan to monitor the client for which of these nutritional consequences of this treatment?

• Hypercalcemia.
• Hyperglycemia.
• Hyponatremia.
• Hypolipidemia. hyperglycemia After ten months on dialysis, a client undergoes a renal transplant and is receiving immunosuppressive therapy. Which of these nutritional consequences should a nurse anticipate?
• A decreased synthesis of bile acids will occur.
• An increased intake of simple carbohydrates will be necessary.
• The client's protein requirements will be significantly higher.
• The client's need for fat-soluble vitamins will be greater. The client's protein requirements will be significantly higher. Assuming that all of these foods are available, which sandwich selection would be appropriate for a client who is on a bland diet of 50 grams of fat?
• Peanut butter and jelly on whole wheat bread.
• Creamy chicken salad and tomato on rye bread.
• Flaked white tuna and lettuce on white bread.
• Bologna and American cheese with maynonnaise on white bread.

Flaked white tuna and lettuce on white bread Following a partial gastrectomy, a client loses the ability to synthesize intrinsic factor. As a result, a nurse should expect that the patient will be unable to absorb which of these nutrients?

• Vitamin B12.
• Copper.
• Folacin.
• Iron vitamin b When preparing a diet plan for diabetic client, a nurse should recognize that which of these foods would be found in the bread/starch exchange list?
• Green peas.
• Avocado.
• Broccoli.
• Beets. green peas Which if these diet orders should a nurse give initially to a client who has acute pancreatitis?
• Hydrolyzed protein formula.
• Nothing by mouth.
• Pureed soft diet.
• Two grams of sodium, 30 grams of fat. nothing by mouth

Which of these is a major disadvantage of a clear liquid diet?

• Fluids allowed are not palatable.
• High caloric content results in hyperglycemia.
• High fluid intake leads to diarrhea.
• Diet is nutritionally inadequate. Diet is nutritionally inadequate. Which of these diets should a nurse implement for a woman who is recovering from hyperemesis of pregnancy?
• High-protein liquids every two hours.
• Foods that are high in soluble fiber divided equally throughout the day.
• Frequent meals of soft, bland foods.
• Frequent small, dry meals, with clear liquids in between. Frequent small, dry meals, with clear liquids in between. Which of these factors should a nurse investigate as the most likely etiology of altered nutrition in a client who is receiving radiation therapy for endometrial cancer?
• Malabsorption.
• Absence of essential enzymes.
• Dysphagia.
• Loss of appetite loss of appetite A client who is receiving continuous bladder irrigation has an intake of 800 mL of intravenous fluid and 2,000 mL of irrigating solution. The urinary drainage bag contains 3,800 mL. The

charted output should be

• 800 mL.
• 1,000 mL.
• 1,800 mL.
• 3,800 mL 1,800 mL A vial of medication contains 150 mg/2 mL. If a client is to receive 25 mg of the medication intramuscularly, how many milliliters should a nurse administer to them?
• 0.2 mL
• 0.3 mL
• 0.6 mL
• 1.0 mL 0.3 mL If 150 mg equals 2 mL, then 75 mg equals 1 mL, so 25 mg would equal 0.3 mL. When caring for a client during the immediate postoperative period after a sub-total thyroidectomy, it is important for a nurse to
• ensure that the client remains in a supine position.
• encourage the client to speak frequently.
• provide the client with oral fluids.
• monitor the client's respiratory status.
• monitor the client's respiratory status

Which of these actions by a nurse would be best when communicating with a client who has expressive aphasia?

• Encourage the client to verbalize thoughts.
• Involve the client's family in interpreting the patient's needs.
• Ask questions of the client that require an affirmative or negative response.
• Attempt to read the client's lip movements. Ask questions of the client that require an affirmative or negative response. A client who has been on nothing by mouth may now have fluids. Which of these beverages should be offered first?
• Skim milk.
• Eggnog.
• Cream of chicken soup.
• Apple juice. Apple juice A nurse should include which of these measures when caring for a client who has returned from hemodialysis?
• Obtaining a post-procedure urine sample from the client.
• Increasing the client's intake of fluids.
• Placing the client in protective isolation.
• Observing the client for signs of shock. Observing the client for signs of shock A client is receiving intermittent nasogastric tube feedings. A nurse should aspirate the residual stomach contents prior to

administering a scheduled feeding for which of these purposes?

• To check the pH of the gastrointestinal fluids.
• To evaluate the osmolarity of the stomach contents.
• To determine absorption of formula in the stomach.
• To obtain a specimen of gastric secretion. To determine absorption of formula in the stomach. Which of the following endocrine system glands is primarily responsible for regulating an individual's metabolism and energy? thyroid gland The force of gravity on a person or object on the surface of a planet is known as which of the following? weight The parathyroid gland is an endocrine system gland located behind the thyroid gland. What does the parathyroid gland help the body control? calcium and phosphorus levels A nurse is counting a client's radial pulse and notes that the pulse is irregular in rate and rhythm. Which of these actions should the nurse take next?
• Have the client rest quietly for 10 minutes, and then take the carotid pulse.
• Monitor the client's radial pulse while another person takes the pulse at another site.
• Lower the client's wrist and then take the radial pulse on both

arms.

• Measure the client's apical heart rate for one full minute. Measure the client's apical heart rate for one full minute. A client develops a neurogenic bladder as a result of a spinal cord injury. To initiate a bladder training program for the client a nurse should plan which of these actions?
• Restrict fluids throughout the day.
• Compress the abdomen before each voiding.
• Pour water over the perineum.
• Observe for patterns of incontinence. Observe for patterns of incontinence. A client reports pain at the needle insertion site of an intravenous infusion. A nurse observes that the area is red. Which of these actions should the nurse take?
• Elevate the solution container and regulate the flow rate.
• Remove the tape and reposition the needle in the vein.
• Stop the infusion and remove the catheter or needle.
• Reduce the flow rate of the fluid and elevate the extremity. Stop the infusion and remove the catheter or needle. A client is to receive 200 mL of three-quarter-strength tube feeding. Which of these proportions should a nurse administer?
• 100 mL of feeding and 100 mL of water.
• 125 mL of feeding and 75 mL of water.
• 150 mL of feeding and 50 mL of water.
• 175 mL of feeding and 25 mL of water.

150 mL of feeding and 50 mL of water. A nursing home client has been confined to a geriatric chair for two hours. Which of these measures should a nurse take at this time?

• Give the client a bed bath.
• Sit and talk with the client for ten minutes.
• Walk with the client around the unit.
• Encourage the client to socialize with the roommate. Walk with the client around the unit. Which of these measures should a nurse include in the care plan of a client who has renal calculi?
• Restricting fluid intake.
• Straining all urine.
• Maintaining bed rest.
• Limiting potassium intake. straining all urine A nurse is reinforcing discharge instructions with a client who is on warfarin sodium (Coumadin) therapy. Which of these instructions should be emphasized?
• Brush your teeth after meals with a firm toothbrush.
• Use an electric razor for shaving.
• Take aspirin (ASA) or other NSAID for all minor aches and pains.
• Include plenty of green, leafy vegetables in your diet. Use an electric razor for shaving.

Which of these measures should a nurse emphasize when feeding a client with left-sided facial paralysis who has difficulty swallowing?

• Placing the food on the back of the client's tongue.
• Placing the food in the unaffected side of the client's mouth.
• Removing the client's dentures before feeding.
• Mashing the food before feeding the client. Placing the food in the unaffected side of the client's mouth. Which of these actions should a nurse take to prevent the development of thrombophlebitis in a postoperative client?
• Raise the knee gatch on the client's bed.
• Ambulate the client.
• Encourage the client to increase fluid intake.
• Massage the client's legs. ambulate the client A client who is terminally ill with acquired immunodeficiency syndrome (AIDS) is admitted to the hospital. Which of these precautions should be included in the client's plan of care?
• Standard precautions.
• Respiratory precautions.
• Strict isolation.
• Enteric precautions. standard 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 of these actions should a nurse include in the plan of care?

• Keep the system below the level of the client's waist.
• Change the system every 72 hours.
• Empty the system every 4 hours.
• Clamp the system when ambulating the client. Keep the system below the level of the client's waist. A nurse identifies all of these nursing diagnoses for a client. Which diagnosis should the nurse give the highest priority?
• Altered comfort: pain.
• Altered nutrition: less than body requirements.
• Impaired skin integrity.
• Impaired tissue perfusion. Impaired tissue perfusion. A nurse is helping an elderly client who has been on prolonged bed rest to get out of bed for the first time. The client should be encouraged to move slowly in order to prevent
• sudden perfusion of the kidneys.
• engorgement of the femoral veins.
• postural hypotension.
• increased cardiac output postural hypotension. A nurse obtains all of these laboratory results for a client prior to surgery. Which one should the nurse report to the physician?
• Hemoglobin level of 11.5 gm/dL.

• Prothrombin time of 32 seconds.
• Platelet count of 250,000/mm.
• White blood cell count of 9,000 cells/mm. Prothrombin time of 32 seconds. The results of a client's diagnostic tests show a high total cholesterol level. The client asks a nurse, "What should I do to reduce my cholesterol level?" The nurse should suggest that the client decrease the intake of which of these nutrients?
• Vegetable fats.
• Complex carbohydrates.
• Simple sugars.
• Animal fats. animal fats When cleaning a client's dentures, which of these measures should a nurse implement while wearing gloves?
• Brushing the dentures in an emesis basin with tepid water.
• Soaking the dentures for 20 minutes in a peroxide solution.
• Applying an abrasive dentifrice to the dentures with a stiff brush.
• Rinsing the dentures in the sink using hot tap water. Brushing the dentures in an emesis basin with tepid water. Which of these communication techniques should a nurse use with a client who frequently misinterprets the nurse's instructions?
• Conveying acceptance of the client.

• Listening attentively to the client.
• Offering reassurance to the client.
• Validating information with the client. Validating information with the client. Which of these nursing actions would be most effective in gaining the confidence of an adult client who is anxious?
• Show interest in the client's point of view.
• Relate experiences similar to those of the client.
• Demonstrate a clear understanding of what the client can do to relieve the problem.
• Tell the client about resources that are available. Show interest in the client's point of view A client who is terminally ill with cirrhosis says to a nurse, "I'm angry at God because he won't give me a new liver." Which of these responses would be most helpful?
• "You're angry at God."
• "I understand your anger toward God."
• "I don't blame you for being angry at God.
• "You really need to control your anger toward God. you're angry at god After preparing a liquid cough medication for a client, a nurse asks another nurse to administer the medication. Which of these actions should the second nurse take?
• Administer the medication as requested.
• Pour a new dose of the medication.

• Chart the medication as a missed dose.
• Question the medication order. pour a new dose of the medication It is now eight hours since a male client had minor surgery. He expresses a desire to void but is unable to do so. To assist him in passing urine, which of these actions should a nurse take first?
• Apply gentle pressure over the bladder region.
• Assist the client to a standing position at the bedside.
• Insert a straight catheter into the bladder.
• Increase the client's fluid intake. Assist the client to a standing position at the bedside. The evening before surgery, a client asks a nurse, "Could you pray with me?" The nurse's reply should be based on which of these understandings about the nurse's role in the client's care?
• Meeting the client's need is within the nurse's province if the nurse's faith is the same as the client's.
• The nurse should request the chaplain of the client's faith to visit.
• Prayer is not a nursing function; the nurse should institute such measures as distraction and relaxation.
• The nurse has a responsibility to see that the client's need is met Meeting the client's need is within the nurse's province if the nurse's faith is the same as the client's.

When a client has a nasogastric drainage tube connected to suction, a nurse should monitor the client for symptoms of which of these imbalances?

• Metabolic alkalosis.
• Respiratory alkalosis.
• Metabolic acidosis.
• Respiratory acidosis. Metabolic alkalosis. When assessing a client's lungs, a nurse should auscultate the lungs by using which of these techniques?
• Listen during the inspiratory phase at alternating sites.
• Listen to the entire right side before listening to the left side.
• Listen to the chest while the patient is supine.
• Listen for a full respiratory cycle at each site. Listen for a full respiratory cycle at each site. A 42-year-old client is admitted to a medical unit in acute renal failure. The client is given protein food with a high biological value. A nurse should recognize that the rationale for this diet prescription is to
• minimize the amount of nitrogen that must be excreted.
• increase the amount of urine produced.
• reduce the total amount of caloric intake.
• provide maximum vitamins and minerals per gram of protein. minimize the amount of nitrogen that must be excreted.

A community-based nurse is conducting nutrition education classes at a senior center. The nurse should instruct the clients to consume a high-fiber diet in order to prevent which of these conditions?

• Acute irritable bowel syndrome.
• Duodenal ulcer.
• Gastritis.
• Diverticulosis. Diverticulosis. A nurse is making a home visit to a mother of a 2-month-old baby. The baby has shown signs of failure to thrive. Which of these assessments by the nurse would provide the most useful data?
• Ask the mother about her weight gain during pregnancy.
• Inquire about the family's eating habits.
• Obtain information about the route of the baby's delivery.
• Observe the mother feeding the infant. Observe the mother feeding the infant. A nurse is providing dietary instruction to the mother of a child who has a diagnosis of phenylketonuria. Which of these foods should be eliminated from the child's diet?
• Foods seasoned with monosodium glutamate.
• Foods containing artificial colors.
• Foods high in tyramine.
• Foods sweetened with aspartame.

Foods sweetened with aspartame. An 18-year-old college freshman who has had diabetes mellitus (Type I) for nine years takes isophane (NPH) and insulin injections (regular insulin) in the morning and late afternoon. This client reports not having enough time to get to the cafeteria to eat before the first class. Which of these suggestions should a nurse give the patient?

• Delay taking your morning insulin until you have had breakfast.
• Keep some hard candy available if you need it during class.
• Store food in your room that can be used in your meal plan.
• Eat a larger bedtime snack the night before. Store food in your room that can be used in your meal plan. An 82-year-old client is bedridden in a nursing home. As a result of the client's immobility, a nurse should anticipate that they will experience a loss of
• calcium.
• insulin receptivity.
• iron-binding capacity.
• body fat. calcium Before being diagnosed with acquired immunodeficiency syndrome (AIDS), a client's usual weight was 140 lb (54.43 kg). In the four weeks prior to admission, the patient lost 18 lb (8.16 kg). Based on the data, which of these assessments should a nurse make?

• The client's previous use of drugs has interfered with nutrient absorption.
• The weight loss increases the risk of complications.
• The weight loss is primarily from a loss of fluid.
• The initial loss of weight in AIDS patients is followed by stabilization. The weight loss increases the risk of complications. In evaluating the recovery of a client following a partial gastrectomy for cancer, which of these findings should a nurse interpret as indicating appropriate nutritional rehabilitation?
• A weight gain of one-half to one pound per week.
• A serum glucose of 80 to 100 mg/dL.
• A blood urea nitrogen level less than 8 mg/100 dL.
• A weight gain of two or more pounds per week. A weight gain of one-half to one pound per week. To evaluate how well a client who is on hemodialysis has adhered to the dietary regimen, a nurse should take which of these actions prior to each treatment?
• Review the client's food intake since the last treatment.
• Ask the client about fluid intake during the 24 hours prior to treatment.
• Determine the client's blood glucose level.
• Compare the client's present weight to the weight after the last treatment.