Basic Care and Comfort NCLEX questions
Of the following positions, which one facilitates maximum air exchange? a. Orthopneic b. Trendelenburg c. High Fowler's d. Lithotomy
a. Orthopneic This is sitting in a leaning position, which allows for the most lung expansion.
The nurse prepares a 5-year-old girl for a pre-operative IV insertion. Which statement is most appropriate to reduce the child's anxiety? a. Hold on to your doll, this is going to hurt. b. Just look at the TV while I do this. c. Tell me if this feels more like a pinch or a bug bite. d. It's going to hurt a little, but I know you're a brave girl.
c. Tell me if this feels more like a pinch or a bug bite. Children should be prepared for procedures. Educate them, but don't suggest that there will be pain. Allow them to decide if there is discomfort.
Which meal best promotes healing for a patient recovering from a burn injury? a. pasta marinara, garlic bread, ginger ale b. peanut butter and jelly sandwich, banana, tea c. chicken breast, strawberries, milk d. pork chop, fried potatoes, coffee
c. chicken breast, strawberries, milk The meal with the best nutrition for wound-healing includes protein and vitamin C.
A pregnant client comes to the prenatal clinic for her first visit. The nurse notes that this is the client's third pregnancy. Four years ago, she delivered a healthy boy at 38 weeks, and two years ago, she delivered a healthy girl at 35 weeks. Using the gravida/para system to record the client's obstetrical history, the nurse will document a. Gravida 3 - Para 2 b. Gravida 2 - Para 2 c. Gravida 2 - Para 1 d. Gravida 3 - Para 1
a. Gravida 3 - Para 2 Using the gravida/para system, the nurse should record Gravida 3 - Para 2. The client is pregnant for the third time (Gravida 3) and has had two pregnancies of more than 20 weeks' gestation each (Para 2). The other options are incorrect.
The nurse teaching a 14-year-old client about her cervico-thoracolumbosacral orthosis (CTLSO) brace. Which statement by the client would indicate a lack of understanding about the brace? a. I can take it off in hot weather. b. I should wear loose clothing underneath it. c. I can remove it when I take a shower. d. I must wear it all day and night.
a. I can take it off in hot weather. The Milwaukee brace, also known as a cervico-thoracolumbosacral orthosis or CTLSO, is a back brace used in the treatment of spinal curvatures such as scoliosis or kyphosis in children. It is a full-torso brace that extends from the pelvis to the base of the skull. Its aim is to keep the body upright and prevent progression of the curve while the patient is growing and awaiting possible need for operative intervention. The brace must be worn long term, during periods of growth, usually for 1 to 2 years.
After a high school athlete sustains a fractured femur during a competition, a full leg plaster cast is applied. When the nurse provides discharge instructions to the athlete and their parents six hours later, which statement by the athlete indicates a need for further education? a. I should walk around on my cast as soon as I get home. b. I will prop my cast on two pillows when I lie down. c. I'll put an ice pack over the cast to relieve itching. d. I should call my doctor if my toes turn blue or become numb.
a. I should walk around on my cast as soon as I get home. Plaster casts are made up of a bandage and a hard covering, usually plaster of Paris. Client instructions include: 1) Keep the limb raised on a soft surface for as long as possible in the first few days, this will help decrease swelling. 2) Keep the cast dry; if the plaster gets wet, it weakens and is unable to support the bone. 3) Do not put anything into the cast to relieve itching. A hair dryer on cool or an ice pack over the itchy area can help. 4) Immediately report any pain, tingling, or numbness.
When instructing a patient with Addison's disease about nutrition, the healthcare provider should NOT recommend which of the following dietary modifications? a. a restricted-sodium diet b. a client with adequate caloric intake c. a diet high in grains d. a high-protein diet
a. a restricted-sodium diet A patient with Addison's disease (adrenal insufficiency) requires normal dietary sodium to maintain electrolyte balance and prevent excess fluid loss.
After emptying a Jackson-Pratt drainage bulb, how does the nurse reestablish negative pressure in the system? a. compress the bulb and close the valve b. fill the bulb with sterile saline solution c. place the bulb lower than the client's body d. open the valve and fill the bulb with air
a. compress the bulb and close the valve A Jackson-Pratt drain creates negative pressure when the bulb is compressed and the valve is closed. This causes fluid around the surgical site to flow into the drain.
The purpose of a splint is to a. immobilize and allow for tissue swelling b. wrap around an injury for full protection c. manage complex or unstable fractures d. provide permanent support for a fracture
a. immobilize and allow for tissue swelling The primary purposes of splinting for limb fractures are to protect soft tissue from further damage, allow for tissue swelling, reduce the client's pain, reduce the possibility of a fat embolism, and minimize painful muscular spasms.
A patient receiving chemotherapy is experiencing stomatitis. Which of the following should the healthcare provider offer the patient? a. warm saline rinses four times each day b. vigorous oral care with a commercial mouthwash c. plenty of ice chips between meals d. hot soup for lunch and dinner
a. warm saline rinses four times each day Stomatitis is irritation of the lips, mouth, tongue, and oropharynx, which occurs when chemotherapy kills healthy cells that are rapidly dividing. It can impair nutrition, speech, sleep, and quality of life. Warm saline rinses are non-irritating and help eliminate bacteria that can cause infection.
What is the smallest gauge intravenous catheter that can be used to administer blood? a. 26-gauge b. 20-gauge c. 22-gauge d. 24-gauge
b. 20-gauge An 18-gauge needle or catheter is generally used to administer blood or push fluids, or for testing protocols that require large bore IVs. However, a 20-gauge is acceptable if the facility's policy allows it. This size is better for clients with small veins. A 22-gauge is used for IVs of short duration and for clients not critically ill. A 24-gauge is used for pediatrics and adults who cannot tolerate a larger gauge. A 16-gauge IV is mostly used in ICUs and surgery units because most fluids and blood products can be quickly administered. A 26-gauge needle is used for injections.
The nurse calculates the 1-minute Apgar score for a neonate with the following: 1. Respiratory effort: slow; 2. heart rate: 120 bpm; 3. muscle tone: some flexion of extremities; 4. reflex irritability: vigorous; 5. skin color: body pink, blue extremities. What score does the nurse assign? a. 8 b. 7 c. 10 d. 9
b. 7 Scoring is 0, 1, or 2 for each category. A perfect Apgar score is 10. Scoring categories are as follows: 1. Respiratory effort: 0 = not breathing, 1 = slow or irregular, 2 = strong cry. 2. Heart rate by stethoscope; 0 = no HR, 1 = < 100 bpm, 2 = > 100 bpm. 3. Muscle tone: 0 = loose/floppy, 1 = some tone, 2 = active motion. 4. Reflex irritability or grimace response: 0 = no reaction, 1 = grimacing, 2 = cough, sneeze, or cry. 5. Skin color: 0 = pale blue, 1 = body pink, extremities blue, 2 = entire body pink.
After your patient dies, the patient's family gathers at the bedside and asks you to step out while their clergy performs a religious rite for the deceased. As the patient's nurse, what is your most appropriate course of action? a. Educate the family about custody of care and stay in the room b. Allow the ceremony and step out of the room c. Inform the family that religious rites are not allowed d. Allow the ceremony but remain as a witness
b. Allow the ceremony and step out of the room Most hospitals do not have a policy that prohibits religious rites at the time of death. Remaining in the room shows disrespect and lack of trust a time of grieving.
Which skin care instruction is correct for a male client receiving head and neck radiation therapy? a. Use an antibacterial soap every day b. Avoid shaving with a straight-edge razor c. Cover the treated area with sterile gauze d. Apply lotion right before each treatment
b. Avoid shaving with a straight-edge razor During radiation therapy, the client should use an electric razor to avoid irritation or cuts. Antibacterial soaps are too harsh; a mild soap should be used instead. The radiation area is left open to the air. Lotion may be used several times a day, but not 4-5 hours before a treatment. Lotions or creams should not be applied over the radiation marks.
A patient with a total hip replacement requires certain equipment for recovery. Which of the following will assist the patient with activities of daily living (ADL)? a. TENS unit b. High-seat commode c. Recliner d. Abduction pillow
b. High-seat commode This keeps the hip higher than the knee.
A client returns to the unit after abdominal surgery. While monitoring the client, the nurse observes a moderate amount of red blood on the dressing. The nurse will document this type of wound drainage as a. Purulent b. Sanguineous c. Serosanguineous d. Serous
b. Sanguineous The word comes from the Latin, meaning "blood." Wound drainage is described by type, color, amount, and odor. Types of drainage are: 1. Serous: clear and thin; may be present in a healthy, healing wound. 2. Serosanguineous: containing blood; may also be present in a healthy, healing wound. 3. Sanguineous: primarily blood. 4. Purulent: thick, white, and pus-like; may be indicative of infection and should be cultured
A client has a pressure ulcer on the sacrum. While assessing it, the nurse observes that it has partial thickness, loss of dermis, and a red-pink wound bed. Which stage will the nurse assign this pressure ulcer? a. Stage III b. Stage II c. Stage I d. Stage IV
b. Stage II Stage I pressure ulcers have intact skin with a reddened area that may be firm and painful. Stage II pressure ulcers are indicated by partial thickness, loss of dermis, and a red-pink wound bed. Stage III pressure ulcers have full-thickness skin loss and may contain slough, visible subcutaneous tissue, and tunneling. Stage IV pressure ulcers have full-thickness skin loss and exposed muscle, bone, or tendons.
When a patient's nasogastric (NG) tube stops draining, what is the nurse's first action? a. clamp for 1 hour b. check tube placement c. instill 50 mL of water d. retract 2 inches
b. check tube placement ALWAYS verify tube placement before taking other measures. NEVER put anything in an NG tube unless you know that its tip is in the stomach. Clamping has no effect on NG tube placement. Retracting without knowing where the tip is could be unsafe.
The nurse is providing postmortem care for a client who was being treated for Staphylococcus aureus. Which transmission-based precautions are indicated? a. droplet precautions b. contact precautions c. airborne precautions d. standard precautions
b. contact precautions MRSA is transmitted by contact, and MRSA bacteria remain alive for up to 3 days after the host dies.
A pediatric patient has been diagnosed with right lower lobe pneumonia. Upon auscultation of this lung field, the healthcare provider should expect to hear which breath sounds? a. rhonchi b. crackles c. stridor d. wheezes
b. crackles Crackles would most likely be heard because they indicate fluid in the airspace. Fluid in the airspace is consistent with pneumonia. Wheezes indicate a narrowing of the airway. Stridor is an emergency lung sound that is seen in airway constriction and can lead to complete closure. Rhonchi are heard in mixed-issue airway constriction and secretions.
A client with chronic renal failure (CRF) is learning to perform peritoneal dialysis at home. The nurse instructs the client to warm the dialyzing solution to 37 degrees Celsius so that it will a. remove toxins from the body's cells b. dilate the peritoneal blood vessels c. relax the abdominal muscles d. maintain a constant body temperature
b. dilate the peritoneal blood vessels The rationale for warming the peritoneal dialysis solution is that the warm solution helps dilate peritoneal vessels, which increases urea clearance. Warming dialyzing solution also contributes to client comfort by preventing cold sensations.
Contraindications for administering an enema include all of the following EXCEPT a. suspected appendicitis b. hypercalcemia treatment c. recent colon surgery d. acute MI
b. hypercalcemia treatment An enema may be used to administer sodium polystyrene sulfonate (Kayexalate) for the treatment of hyperkalemia. Kayexalate can be administered either orally or as an enema. Sodium polystyrene sulfonate is not absorbed from the gastrointestinal tract. As the resin passes through the gastrointestinal tract, the resin removes the potassium ions by exchanging them for sodium ions.
When cleaning the perineal area around the site of an indwelling catheter, the nurse should a. scrub the tubing toward the urinary meatus b. wipe the catheter away from the urinary meatus c. apply powder after giving perineal care d. vigorously wash the periurethral area
b. wipe the catheter away from the urinary meatus The catheter should be wiped away from the meatus, to decrease the risk of introducing pathogens into the urinary tract. The perineum should be washed gently with soap and water.
The post-anesthesia care unit (PACU) provides a report to the pediatric nurse on a 15-month-old who has had repair of a congenital hip deformity. What type of traction does the nurse anticipate will be used for the child? a. Buck's b. Russell's c. Bryant's d. Dunlop's
c. Bryant's Bryant's traction is used following surgery to correct a congenital hip deformity. The child's legs are wrapped with moleskin tape and adhesive elastic bandages, which are connected to the traction's ropes and weights. The tension stabilizes the end of the femur in the hip socket as the site heals. Russell's traction is used to align a fractured femur. Buck's traction is skin traction used for femoral, acetabular, and hip fractures as well as low back pain. Dunlop's traction is used on children with certain fractures of the upper arm, when the arm must be kept in a flexed position
The healthcare provider is preparing a patient for a total colectomy and the placement of an ileostomy. The patient asks where the stoma will be located. The healthcare provider identifies which of the following areas as the correct stoma site? a. RUQ b. LUQ c. RLQ d. LLQ
c. RLQ A total colectomy involves the removal of the large intestine. The gastrointestinal output will occur at the terminal end of the ileum. The stoma will be located in the right lower quadrant of the abdomen. A total colectomy is performed for intestinal inflammatory conditions such as Crohn's disease or ulcerative colitis. It may also be done for severe chronic constipation.
A 32-year-old female with no significant history comes to the clinic for a routine check-up. Where is the most appropriate spot to measure this client's pulse? a. Apical b. Femoral c. Radial d. Carotid
c. Radial For a client with an uncomplicated medical history, taking a radial pulse is appropriate. An apical pulse is appropriate for clients taking cardiovascular medications, such as Digoxin. A carotid pulse is appropriate for emergency situations, such as cardiac arrest. Taking a femoral pulse is not necessary and can be considered an invasion of privacy.
The nurse is teaching parents to instill eye drops for their 4-month-old daughter. The parents tell the nurse that she shuts her eyes tightly to avoid the drops. Which instruction by the nurse is most appropriate? a. The parents should instill the drops into the conjunctival sac b. The parents should wait until their daughter is relaxed. c. The parents should put the drops into the inner canthus. d. The parents should open her eyes with a thumb and forefinger.
c. The parents should put the drops into the inner canthus. Infants instinctively resist anything regarding their eyes by tightly closing them. The best way to instill eye drops is to gently restrain the baby's head while the baby is in a supine position, and put the drops in the inner canthus of the eyes.
Despite frequent turning and skin assessment, occasional urinary incontinence has caused a bedridden resident to develop a reddened and tender area on the coccyx. The resident weighs 192 pounds. Which pressure-relieving device should be used for the client? a. low air loss bed b. egg crate foam c. alternating overlay d. natural sheepskin
c. alternating overlay For clients who weigh less than 250 lbs, an alternating pressure overlay is the best choice because it is liquid resistant. It has compartments that alternately inflate and deflate to relieve pressure.
A patient diagnosed with Crohn's disease has a new colostomy. When assessing the patient's stoma, which of these would alert the healthcare provider that the stoma has retracted? a. narrowed and flattened b. dry and reddish purple c. concave and bowl shaped d. pinkish red and moist
c. concave and bowl shaped A healthy stoma will protrude about 2.5 cm with an open lumen at the top. The stoma should appear pinkish red and moist. A dry, dusky, or reddish-purple stoma indicates ischemia. A narrowed, flattened, or constricted stoma indicates stenosis. A concave and bowl-shaped stoma has retracted. A retracted stoma can be difficult to care for.
A client comes to the clinic, complaining of severe gastrointestinal distress. Which abdominal physical assessment step does the nurse do first? a. percussion b. palpation c. inspection d. auscultation
c. inspection The correct sequence for physical assessment of the ABDOMEN is as follows: 1) inspect, 2) auscultate, 3) percuss, 4) palpate The order is different from the physical assessment of the body systems, which is Inspect, Palpate, Percuss, Auscultate
A nurse is caring for a client whose heel has a pressure ulcer covered with intact hard, dry, black tissue. Which is the appropriate dressing for this client? a. do a wet-to-dry dressing change b. cover with sterile gauze c. no dressing is necessary d. apply a hydrocolloid dressing
c. no dressing is necessary Current standard of care guidelines recommend that stable, intact (dry, adherent, intact without erythema) eschar on the heels should not be removed. Eschar works as a natural barrier or biological dressing by protecting the wound bed from bacteria. Unless it is wet, draining, or loose, it should remain in place.
A client with end-stage renal disease has opted for an arteriovenous (AV) fistula for long-term treatment with hemodialysis. Following the surgical creation of the AV fistula, when will the client be able to use it for hemodialysis? a. 4-6 months b. 4-6 weeks c. 2-3 weeks d. 2-3 months
d. 2-3 months An AV fistula is a connection of an artery to a vein, created by a vascular surgeon. An AV fistula frequently requires 2 to 3 months to develop or mature before the patient can use it for long-term hemodialysis.
A client with a diagnosis of congestive heart failure (CHF) is placed on strict intake and output (I&O). The unlicensed assistive personnel (UAP) records the client's intake at lunch as 8 oz. of black coffee, 6 oz. of orange juice, 4 oz. of lime jello, and 4 oz. of vanilla pudding. What is the client's intake? a. 240 mL b. 420 mL c. 660 mL d. 540 mL
d. 540 mL Intake is considered any food that is liquid at room temperature. The client's intake is 8+6+4=18 fluid ounces. 1 fluid ounce = 30 mL, so 18 ounces = 540 mL. Pudding is not included, because it is not a liquid at room temperature. Liquids include coffee, tea, milk, soft drinks, water, gelatin (jello), broth, ice cream, popsicles, sorbet, and nutritional supplement drinks, such as Ensure. Note: Ice chips melt to half their volume. For example, if the client receives 8 oz. of ice chips, record the intake as 4 oz.
To measure an adult client's apical heart rate, where does the nurse place the stethoscope? a. Third left intercostal space at midclavicular line b. Second left intercostal space at midclavicular line c. Fourth left intercostal space at midclavicular line d. Fifth left intercostal space at midclavicular line
d. Fifth left intercostal space at midclavicular line FILM = Fifth Intercostal Midclavicular Line. The apical pulse is auscultated with a stethoscope over the chest where the heart's mitral valve is best heard. For adults, the point of maximum pulse is the fifth left intercostal space at the midclavicular line. In infants and young children, the apical pulse is located at the fourth intercostal space at the left midclavicular line.
The nurse is educating a client with primary adrenal insufficiency (Addison's disease) on diet and nutrition changes needed to manage the client's disease. Which statement by the client would indicate that the nurse's instructions have been effective? a. I should increase fluids, but limit sodium and potassium b. I will increase potassium and fluids, but limit sodium c. I will increase sodium and potassium, but limit fluids d. I should increase sodium and fluids, but limit potassium
d. I should increase sodium and fluids, but limit potassium Addison's disease develops when the adrenal glands are damaged. They don't make enough of the hormones cortisol and aldosterone. Besides corticosteroid medications, dietary changes include increased sodium, decreased potassium, and adequate fluid intake.
A client with a severe ankle sprain will be using crutches. Which of the following indicates that the crutches have been fitted correctly? a. The client's elbow is locked with the hand on the handgrip b. The client's axilla rests on the crutch pad when the client ambulates c. The client's axilla is at the same level as the top of the crutch d. The client's elbow is at a 30-degree angle with the hand on the handgrip
d. The client's elbow is at a 30-degree angle with the hand on the handgrip Proper crutch measurements result in the client's weight being on the hands, not the axilla. This avoids damage to the brachial plexus. The elbow should be at a 30-degree flex, not straight. The top of the crutch should be 2 to 3 finger widths lower than the axilla.
Before administering a scheduled 300 mL enteral feeding bolus to a comatose adult client, the nurse aspirates 100 mL of gastric residual volume. Which nursing action is MOST appropriate? a. hold the feeding bolus for two hours b. flush the tubing with warm water c. request a different enteral formula d. administer the bolus as prescribed
d. administer the bolus as prescribed Standard practice includes measuring gastric residual volume prior to administering an enteral feeding. Enteral feedings can be administered with a residual up to 500 mL.
The nurse is instructing a client with a new sigmoid colostomy about caring for the colostomy. The nurse explains that to best regulate the bowel, the client should perform colostomy irrigation at the same time every day. What is the optimal time for doing this? a. two hours before bedtime b. an hour before a meal c. every two hours all day d. an hour after a meal
d. an hour after a meal Colostomy irrigation is a way to regulate bowel movements by emptying the colon at a scheduled time. It distends the bowel to stimulate peristalsis and promote evacuation. It's most effective when performed about an hour after a meal, when the colon is most likely to be full.
The nurse does an admit for a client with a diagnosis of pleural effusion. When doing a respiratory assessment of this client, the nurse will determine if the client has a. increased bronchial breath sounds on the affected side b. a decreased respiratory rate and use of accessory muscles c. increased percussion sounds at the area of effusion d. decreased chest expansion on the affected side
d. decreased chest expansion on the affected side A pleural effusion is a collection of fluid between the pleural layers of the lung. The fluid prevents chest expansion on the affected side. Respiratory rate increases and use of accessory muscles can be observed. Breath sounds are decreased because ventilation on the affected side is also decreased. Resonance is dull and flat to percussion.
Which type of ostomy puts a client at the MOST risk for skin breakdown? a. sigmoid colostomy b. ileal conduit c. transverse colostomy d. ileostomy
d. ileostomy The ostomy type and leakage are major risk factors for skin complications. Ileostomy patients have been found to be at significantly greater risk of developing skin complications than colostomy patients. Ileostomy output, which is from the small intestine, is of a continuous, liquid nature. This output contains gastric and enzymatic agents that when present on skin can denude the skin in a few hours
Which of the following assessment findings is consistent with an extracellular fluid volume deficit? a. bradycardia b. hypertension c. hyperglycemia d. oliguria
d. oliguria Oliguria is a sign of an extracellular fluid volume deficit. Extracellular fluid is the body fluid not contained within individual cells. It constitutes about 20% of our body weight and includes blood plasma, lymph, spinal cord fluid, and the fluid between cells. Importantly, this fluid isn't just water; it contains electrolytes and other essential solutes. Common causes of oliguria are blood loss, vomiting and diarrhea, polyuria, excessive sweating, and burns. The other answer options are not related to fluid deficit or hypovolemia.
During assessment, the home health nurse learns that the client has a fecal impaction. Before proceeding to manually remove the stool, what is the nurse's PRIORITY? a. advise the family to increase the client's fluid and fiber intake b. teach family members to perform the disimpaction process c. give an analgesic or sedative to make the client comfortable d. recall that cardiac dysrhythmias are a possibility
d. recall that cardiac dysrhythmias are a possibility Cardiac dysrhythmias and reflex bradycardia can occur from vagal nerve stimulation.
The nurse is educating a client who is scheduled for surgery for a descending colostomy. Which type of stool should the client expect after the surgery? a. normal and formed b. liquid to semi-liquid c. liquid to semi-formed d. semi-formed to formed
d. semi-formed to formed The stool of a descending or sigmoid colostomy is semi-formed to formed, because much of the water has already been absorbed. The stool is firmer than that of a transverse colostomy and does not contain caustic enzymes.
A client with diabetes insipidus has urine output described as
polyuria Polyuria is a primary symptom of diabetes insipidus, with urine output more than 3 L/day. These clients have decreased or absent vasopressin secretion, which causes water loss in the urine and increased serum sodium. Anuria is the absence of urine output. Oliguria is urine output of less than 500 mL/day. Dysuria is difficult or painful urination.
