NCLEX Prep: Basic Comfort & Care

The nurse is caring for a comatose older adult with stage 3 pressure injuries over two bony prominences. Which intervention should be added to the plan of care? a. Place lamb's wool under the lift sheet. b. Turn the client every 2 to 4 hours. c. Use an egg crate mattress. d. Place the client on a pressure redistribution bed.

d. Place the client on a pressure redistribution bed. A pressure redistribution bed will allow for constant motion of the client and prevent further breakdown. Lambs' wool may trap heat and exacerbate skin breakdown. Turning should be at a minimum of every 2 hours. Egg crate has not been proven to be effective to prevent the development of pressure injuries and should not be used.

The client has had a myocardial infarction, and the nurse has instructed the client to prevent Valsalva's maneuver. The nurse determines the client is following the instructions when the client: a. assumes a side-lying position. b. clenches the teeth while moving in bed. c. drinks fluids through a straw. d. avoids holding the breath during activity.

d. avoids holding the breath during activity. Valsalva's maneuver, or bearing down against a closed glottis, can best be prevented by instructing the client to exhale during activities such as having a bowel movement or moving around in bed.Valsalva's maneuver is not prevented by having the client assume a side-lying position.Clenching the teeth will likely contribute to Valsalva's maneuver, not inhibit it.Drinking fluids through a straw has no effect on preventing or causing Valsalva's maneuver.

A client is being evaluated for hypothyroidism. To plan care, the nurse should ask the client about which sign or symptom? a. weight loss b. diarrhea c. corneal abrasion d. fatigue

d. fatigue A major problem for the person with hypothyroidism is fatigue. Other signs and symptoms include lethargy, personality changes, generalized edema, impaired memory, slowed speech, cold intolerance, dry skin, muscle weakness, constipation, weight gain, and hair loss. Incomplete closure of the eyelids, hypermetabolism, and diarrhea are associated with hyperthyroidism.

Which expected outcome about nutrition would be appropriate for a client who has had a total gastrectomy for gastric cancer? The client will: a. regain any weight lost within 4 weeks of the surgical procedure. b. eat three full meals a day without experiencing gastric complications. c. learn to self-administer enteral feedings every 4 hours. d. maintain adequate nutrition through oral or parenteral feedings.

d. maintain adequate nutrition through oral or parenteral feedings. An appropriate expected outcome is for the client to maintain nutrition either through oral or total parenteral feedings. Oral and total parenteral nutrition may also be used concurrently.It is not realistic to expect the client to regain weight loss within 4 weeks of surgery.After surgery, it is recommended that the client eat six small meals a day rather than three full meals to decrease symptoms of dumping syndrome.Enteral feedings are not part of the expected outcome for gastric surgery.

The nurse is reviewing the intraoperative record of a client. Which information would alert the nurse to the greatest possibility of a potential for skin breakdown? a. use of dorsal recumbent position b. length of surgery c. provision of general anesthesia d. transfer to stretcher

b. length of surgery The client length of time in surgery is the most important factor here since the procedure lasted over 9 hours with the client in the dorsal recumbent position. This position is standard for surgery and the length of time would have given the client pressure on bony prominences since there was not a position change. Having general anesthesia is a factor in other potential surgery complications, and there is no evidence that the transfer to stretcher involved any shearing or friction.

A client hospitalized with Crohn's disease is experiencing a migraine aura. The client requests that the client's chiropractor be allowed to visit even though it is after visiting hours. What is the nurse's best response? a. "Tell me what helps your migraines outside of the hospital." b. "Chiropractors are not real doctors and cannot practice here." c. "I can bring you a PRN medication for your migraine." d. "You can't have a visitor if you are having migraine pain."

a. "Tell me what helps your migraines outside of the hospital." Unless previous arrangements have been made for chiropractic care or craniosacral therapeutic massage, the nurse should engage the client in a discussion of what treatments have been helpful outside of the hospital. This is best done before the full migraine symptoms present. It is demeaning and opinionated to dismiss chiropractors as not "real doctors." Offering a medication may be premature without a full migraine assessment history. The nurse must also have full knowledge of all available medication orders to offer medication at this point. Having pain is not a reason to deny a client from having a visitor.

A client with bipolar disorder, manic phase, shows little interest in eating. What should the nurse do to help the client meet recommended daily allowances of nutrients? a. Give the client half of a meat and cheese sandwich to carry with him. b. Inform the client that snacks are available only if he eats properly at mealtime. c. Tell the client to sit alone at mealtime so that he will not be distracted by others. d. Teach the client about proper nutrition.

a. Give the client half of a meat and cheese sandwich to carry with him. The best nursing intervention is giving the client finger foods high in protein and calories that he can eat while he paces or walks. Informing the client that snacks are available if he eats properly at mealtime is inappropriate because the client is too busy and distracted to sit and eat an entire meal. Telling the client to sit alone at mealtime to decrease distractions will not help him, because the client is in a manic state, is easily distracted, and needs to move. Teaching the client about proper nutrition ignores his need for adequate intake. The client would be unable to focus on the nurse's teaching.

The nurse is teaching a client with multiple sclerosis about prevention of urinary tract infection (UTI) and renal calculi. Which nutrition recommendations by the nurse would be the most likely to reduce the risk of these conditions? a. Increase fluids (2500 mL/day) and maintain urine acidity by drinking cranberry juice. b. Drink a large amount of fluids, especially milk products, and eat a diet that includes multiple sources of vitamin D. c. Eat foods containing vitamins C, D, and E, and drink at least 2 L of fluid a day. d. Eat foods and ingest fluids that will cause the urine to be less acidic.

a. Increase fluids (2500 mL/day) and maintain urine acidity by drinking cranberry juice. Increasing fluid intake will provide an internal irrigation and dilute the urine. This will lessen the probability of renal calculi forming. Cranberry juice is helpful in acidifying the urine and lessening the incidence of cystitis. Ingesting large amounts of milk and vitamin D will not decrease incidence of a UTI or renal calculi. Foods containing vitamins will not necessarily prevent these problems, nor will less acidic urine.

A deceased client is a member of a culture where the family is expected to bathe the body after death. What should the nurse do to support the client and family at this time? a. Provide the needed supplies to the family. b. Participate with the family when bathing the body. c. Ask the family to observe the nurse bathing the body. d. Explain that facility personnel are responsible for the task of bathing.

a. Provide the needed supplies to the family. In cultures where the family is expected to bathe the body, the family should be given the necessary supplies and left alone in the room with the body. The nurse should not interfere by participating with the family or directing the bathing procedure. The nurse should not bathe the body and expect the family to observe the process. Cultural practices are to be acknowledged and honored and facility personnel can permit the family to complete the task of bathing.

A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, the nurse must remain alert for a. diaphoresis, vomiting, and diarrhea. b. manifestations of electrolyte disturbances. c. manifestations of hypoglycemia. d. constipation, dehydration, and hypercapnia.

a. diaphoresis, vomiting, and diarrhea. The nurse must monitor for diaphoresis, vomiting, and diarrhea because these signs suggest an intolerance to the ordered enteral feeding solution. Other signs and symptoms of feeding intolerance include abdominal cramps, nausea, aspiration, and glycosuria. Electrolyte disturbances, constipation, dehydration, and hypercapnia are complications of enteral feedings, not signs of intolerance. Hyperglycemia, not hypoglycemia, is a potential complication of enteral feedings.

A female client reports to a nurse that she experiences a loss of urine when she jogs. The nurse's assessment reveals no nocturia, burning, discomfort when voiding, or urine leakage before reaching the bathroom. The nurse explains to the client that this type of problem is called: a. stress incontinence. b. total incontinence. c. functional incontinence. d. reflex incontinence.

a. stress incontinence. Stress incontinence is a small loss of urine with activities that increase intra-abdominal pressure, such as running, laughing, sneezing, jumping, coughing, and bending. These symptoms occur only in the daytime. Functional incontinence is the inability of a usually continent client to reach the toilet in time to avoid unintentional loss of urine. Reflex incontinence is an involuntary loss of urine at predictable intervals when a specific bladder volume is reached. Total incontinence occurs when a client experiences a continuous and unpredictable loss of urine.

A nurse consulting with a nutrition specialist knows it's important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate for this client? a. full-liquid b. high-protein c. 1,800-calorie ADA d. low-fat

b. high-protein Breathing is more difficult for clients with COPD, and increased metabolic demand puts them at risk for nutritional deficiencies. These clients must have a high intake of protein for increased calorie consumption. Full liquids, 1,800-calorie ADA, and low-fat diets aren't appropriate for a client with COPD.

An adolescent, age 14, is hospitalized for nutritional management and drug therapy after experiencing an acute episode of ulcerative colitis. Which nursing intervention is appropriate? a. administering digestive enzymes before meals as ordered b. providing small, frequent meals c. administering antibiotics with meals as ordered d. providing high-fiber snacks

b. providing small, frequent meals Clients with ulcerative colitis, an inflammatory bowel disorder (IBD), tolerate small, frequent meals better than a few large meals daily. Eating large amounts of food may exacerbate the abdominal distention, cramps, and nausea IBD typically causes. Frequent meals also provide the additional calories needed to restore nutritional balance. This adolescent doesn't lack digestive enzymes and therefore doesn't need enzyme supplementation. Antibiotics are contraindicated because they may interfere with the actions of other ordered drugs and because ulcerative colitis isn't caused by bacteria. High-fiber foods may irritate the bowel further.

An adolescent client is diagnosed with borderline personality disorder (BPD). The client has an eating disorder behavior consisting of eating and then purging. Which of the following questions by the nurse is the best way to assess the client's nutritional status? a. "What are your feelings about an acceptable weight?" b. "Has food always been a problem?" c. "What do you eat in a day?" d. "Do you have a reason for purging?"

c. "What do you eat in a day?" This is the best way to assess the client's usual food intake. The nurse can ask questions and learn about the client's usual eating patterns. "Has food always been a problem?" is a closed-ended question that will not encourage the client to explore the issues related to the problem or to assess nutritional status. "What are your feelings about an acceptable weight?" explores feelings but does not give a description of the client's nutrition. It is difficult for the client to respond to the nurse with a reason for the purging behavior with "do you have a reason..." questions.

Which intervention should the nurse implement to help minimize joint pain in a child with rheumatic fever? a. Massage the affected joints. b. Apply ice to the affected joints. c. Limit movement of the affected joints. d. Encourage progressive weight bearing.

c. Limit movement of the affected joints. In rheumatic fever, the joints—especially the knees, ankles, elbows, and wrists—are painful, swollen, red, and hot to the touch. Limiting movement of the affected joints typically minimizes pain.Massaging the joints likely will not aid in pain relief because the pain is due to the disease process and subsequent inflammation in the joint.Applying ice to the affected joints likely will not aid in pain relief because of the inflammation, edema, and effusion is too deep in the joint tissue.Exercise should be avoided because of the increased workload placed on the heart muscle. This is in contrast to usual recommendations for clients with other forms of arthritis. Despite joint involvement in rheumatic fever, permanent deformities do not occur.

After nasal surgery, the client expresses concern about how to decrease facial pain and swelling while recovering at home. Which instruction would be most effective for decreasing pain and edema? a. Take analgesics every 4 hours around the clock. b. Use corticosteroid nasal spray as needed to control symptoms. c. Use a bedside humidifier while sleeping. d. Apply cold compresses to the area.

d. Apply cold compresses to the area. Applying cold compresses helps to decrease facial swelling and pain from edema. Analgesics may decrease pain, but they do not decrease edema. A corticosteroid nasal spray would not be administered postoperatively because it can impair healing. Use of a bedside humidifier promotes comfort by providing moisture for nasal mucosa, but it does not decrease edema.

A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take? a. Talk slowly and enunciate each word. b. Switch topics frequently to keep the client's attention. c. Talk in a louder than normal voice. d. Face the client and establish eye contact.

d. Face the client and establish eye contact. When speaking with a client who has aphasia, the nurse should face the client and establish eye contact. Enunciating each word is unnecessary. The nurse should allow the client at least 30 seconds to respond to questions or follow a command. Clients with aphasia may need more time to process and understand information. Nurses should use short, simple sentences and avoid frequently changing topics. It is unnecessary to speak in a louder or softer voice than normal.

Which action should be included in the nursing care for a client with cervical cancer who has an internal radium implant in place? a. Offer the bedpan every 2 hours. b. Provide perineal care twice daily. c. Check the position of the applicator hourly. d. Offer a low-residue diet.

d. Offer a low-residue diet. Bowel movements can be difficult with the radium applicator in place. The purpose of the low-residue diet is to decrease bowel movements. The bowel is cleaned before therapy, and the woman is maintained on a low-residue diet during treatment to prevent bowel distention and defecation. To prevent dislodgment of the applicator, the client is maintained on strict bed rest and allowed only to turn from side to side. Perineal care is omitted during radium implant therapy, although any vaginal discharge should be reported to the health care provider (HCP). It is rare for the applicator to extrude, so this does not need to be checked every hour.