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(NACE) I PN-RN: Foundations of Nursing
Practice Test Questions
An Alzheimer patient is actively resistive to basic hygiene. However, in order to meet basic standards for hygiene, how frequently should the patient be bathed? Biweekly Weekly Two to three times weekly Daily - Correct Answers ✅Two to three times weekly While adults don't usually need daily baths, they should bathe two to three times weekly. Grab bars, shower or tub seats, tub mats, handheld showers, and proper heating (to avoid chilling the patient) can facilitate more frequent bathing. Mild soap and bath oil may reduce the drying of skin. Patients who are fearful of tubs and showers, common with dementia, may receive a sponge bath or Comfort Bath with premoistened, warmed washcloths. Thick-handled toothbrushes or electric toothbrushes may facilitate mouth care. At which time of day are patients with cognitive impairment usually MOST sensitive to sensory overload? Late evening Noon Afternoon Early morning - Correct Answers ✅Afternoon
(NACE) I PN-RN: Foundations of Nursing
Practice Test Questions
Many people are more sensitive to sensory overload in the afternoon when cortisol levels are highest. Sensory overload most often affects those with cognitive impairment or those in stressful situations. Excess noise and activity can cause distress, agitation, confusion, and delirium. Sensory deprivation occurs when there is too little environmental stimulation because of reduction in sensory input because of hearing or vision deficits, inability to recognize sensory input because of cognitive impairment, or a boring environment. Sensory deprivation can contribute to confusion, disorientation, and depression. Which of the following is characteristic of nociceptive pain? Burning, stabbing, or shooting pains Diffuse or cramping pain Acute aching or throbbing pain localized to the site of injury Association with chronic conditions such as diabetes or cancer - Correct Answers ✅Acute aching or throbbing pain localized to the site of injury Nociceptive pain usually correlates with the extent and type of injury: the greater the injury, the greater the pain. It may be procedural pain (related to wound manipulation and dressing changes) or surgical pain (related to the cutting of tissue). It may also be continuous or cyclic, depending upon the type of injury. This type of pain, often described as aching or throbbing, is usually localized to the area of injury and resolves over time as healing takes place, and it usually responds to analgesia.
(NACE) I PN-RN: Foundations of Nursing
Practice Test Questions
Which of the following injection sites is the BEST choice for intramuscular (IM) administration of 3 mL of medication for a well- developed adult female of normal weight? Deltoid Vastus lateralis Dorsogluteal site Ventrogluteal site - Correct Answers ✅Ventrogluteal site The ventrogluteal site is the preferred IM injection site because there is little danger of injecting into fatty tissue, large nerves, or blood vessels. In a well-developed adult, up to 4 mL can be safely injected. The dorsogluteal site is the least preferred site because of its proximity to the sciatic nerve and large blood vessels and increased fat deposits. The vastus lateralis site is also good because it lacks large nerves or large blood vessels. The deltoid site is usually avoided because of the small muscle size and the proximity of the radial nerve and artery. Injections to the deltoid should be limited to 1 mL. A burn patient is upset and argues loudly with the nurse, refuses wound care, and states that the treatment is too painful. Which response is an example of therapeutic communication? "You should be happy that the burns are healing so well" "You should stop arguing with the nurses"
(NACE) I PN-RN: Foundations of Nursing
Practice Test Questions
"Everyone gets upset at times" "Let's talk about this and see if we can figure out a way to make the treatment more comfortable for you" - Correct Answers ✅"Let's talk about this and see if we can figure out a way to make the treatment more comfortable for you" Collaborating with the patient to find a solution to a problem is an example of therapeutic communication. The other responses are nontherapeutic and can block effective communication. Saying "Everyone gets upset at times" devalues the patient's feelings. "You should stop arguing with the nurses" is a negative judgment that may anger the patient more and does not deal with the real issue. Saying "You should be happy the wound is healing" provides unwanted advice and ignores the patient's concerns. According to Maslow's hierarchy of needs, which of the client's needs must be met FIRST? Belonging and self-esteem Physiological Safety and security Self-actualization - Correct Answers ✅Physiological Physiological needs must be met first. Abraham Maslow stated that human behavior is motivated by needs, and that there is a hierarchy of needs that begins with basic needs and progresses to personal needs. People may not progress in one direction from one need to another,
(NACE) I PN-RN: Foundations of Nursing
Practice Test Questions
Tell the patient that he may die without the transfusion Provide full information and the reasons for the transfusion Assume the patient will not accept a transfusion and report this to the physician Tell the patient that his health is more important than religious beliefs - Correct Answers ✅Provide full information and the reasons for the transfusion It's important to approach the patient/family with full information and reasons for the transfusion or blood components without being judgmental, allowing them to express their feelings. One should never assume that an individual would refuse blood products based on religion alone. Jehovah's Witnesses can receive fractionated blood cells, thus allowing hemoglobin-based blood substitutes. The following guidelines are provided to church members: When the nurse enters the room of a patient whose death is imminent, the daughter states, "I can't stay in the room when Dad dies! I can't stand the thought!" Which of the following is the BEST response? "I'll stay with him, and you can come and go as you feel comfortable" "Is there someone else who can stay with him?" "Your father would want you with him" "You will regret it if you don't" - Correct Answers ✅"I'll stay with him, and you can come and go as you feel comfortable"
(NACE) I PN-RN: Foundations of Nursing
Practice Test Questions
The nurse should remain supportive and nonjudgmental. Saying "I'll stay with him, and you can come and go as you feel comfortable" supports the daughter's stated desire while still leaving open the opportunity for her to spend time with her father during the death vigil. People react in very different ways to death, and many people have never seen a deceased person and may be very frightened. While many people find comfort in being with a dying friend or family member, this should never be imposed on anyone. Which of the following terms is used to describe the biological effects of drugs over time? Half-time Pharmacokinetics Effect-site equilibrium Pharmacodynamics - Correct Answers ✅Pharmacodynamics Pharmacodynamics relates to the biological effects (therapeutic or adverse) of drug administration over time. Considerations include drug transport, absorption, means of elimination, and half-life. Pharmacokinetics relates to the effect the body has on the drug, considering the route of administration, absorption, dosage, frequency of administration, distribution, and serum levels achieved over time. The half-time is the time needed to reduce plasma concentrations to 50% during elimination. Usually the equivalent of five half-times is needed to completely eliminate a drug or achieve steady-state plasma
(NACE) I PN-RN: Foundations of Nursing
Practice Test Questions
Which of the following is a legal document that specifically designates someone to make decisions regarding medical and end-of-life care if a patient is mentally incompetent? Do-not-resuscitate order General power of attorney Advance directive Durable power of attorney - Correct Answers ✅Durable power of attorney The legal document that designates someone to make decisions regarding medical and end-of-life care if a patient is mentally incompetent is a durable power of attorney. This is a type of advance directive, which can include living wills or specific requests of the patient regarding treatment. A do-not-resuscitate order indicates that the patient does not want resuscitative treatment for terminal illnesses or conditions. A general power of attorney allows a designated person to make decisions for a person over broader areas, including financial. Which of the following is advised to promote phase delay in a patient with circadian rhythm sleep disorder? Avoid early morning light, and seek bright light in the evening Exposure to light after the time of minimum body temperature (about 3 a.m.)
(NACE) I PN-RN: Foundations of Nursing
Practice Test Questions
Walk outside in sunlight after awakening Avoid bright light in the evening - Correct Answers ✅Circadian rhythm sleep disorder (CRSD) is characterized by advanced phase sleep disorder (APSD), delayed phase sleep disorder (DPSD), free-running disorder, shift-work disorder, and other irregular patterns. To promote phase delay:• Expose to light immediately before time of minimum body temperature (about 3 a.m.).• Avoid early morning light and/or wear sunglasses and seek bright light in the evening. To promote phase advance:• Expose to light after the time of minimum body temperature (about 3 a.m.).• Walk outside in sunlight after awakening, and avoid bright light in the evening.• Take a melatonin supplement in the evening.
