NCLEX Basic Care & Comfort
A child, age 2, with a history of recurrent ear infections is brought to the clinic with a fever and irritability. To elicit the most pertinent information about the child's ear problems, the nurse should ask the parent: a) "Does your child tug at either ear?" b) "Does anyone in your family have hearing problems?" c) "Does your child have any hearing problems?" d) "Does your child's ear hurt?"
"Does your child tug at either ear?" Explanation: Although all of the options are appropriate questions to ask when assessing a young child's ear problems, questions about the child's behavior, such as "Does your child tug at either ear?" are most useful because a young child usually can't describe symptoms accurately.
An obese 36-year-old multigravid client at 12 weeks' gestation has a history of chronic hypertension. She was treated with methyldopa before becoming pregnant. When counseling the client about diet during pregnancy, the nurse realizes that the client needs additional instruction when she makes which statement? a) "I need to consume more fluids and fiber each day." b) "I need to reduce my caloric intake to 1,200 calories a day." c) "A regular diet is recommended during pregnancy." d) "I should eat more frequent meals if I get heartburn."
"I need to reduce my caloric intake to 1,200 calories a day." Correct Explanation: Pregnancy is not the time for clients to begin a diet. Clients with chronic hypertension need to consume adequate calories to support fetal growth and development. They also need an adequate protein intake. Meat and beans are good sources of protein.
The nurse is caring for a 7-year-old child who has just returned from the postoperative unit after surgery. The child is playing in bed with toys. The child's parents are smiling and state, "Isn't it great that our child does not have any pain?" What is the best response by the nurse? a) "The child's activity level is the best indicator of pain." b) "Some children distract themselves with play while in pain." c) "A child who resumes usual play is not experiencing pain." d) "Children don't experience as much pain after surgery as adults."
"Some children distract themselves with play while in pain." Correct Explanation: Some children distract themselves with play or music while in pain and may sleep as a result of exhaustion.
A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client? a) By supplying a magic slate or similar device b) By placing the call button under the client's pillow c) By suctioning the client frequently d) By providing a tracheostomy plug to use for verbal communication
By supplying a magic slate or similar device Correct Explanation: The nurse should use a nonverbal communication method, such as a magic slate, note pad and pencil, and picture boards (if the client can't write or speak English).
Which of the following interventions would likely be most effective for the client to use at home when managing the discomfort of rhinoplasty 2 days after surgery? a) Lying in a prone position. b) Applying ice compresses. c) Blowing the nose gently. d) Applying warm, moist compresses.
Applying ice compresses. Explanation: The most effective way to decrease discomfort is to decrease local edema. Cold application, such as an ice compress or ice bag, is effective.
An adolescent is diagnosed with iron deficiency anemia. After emphasizing the importance of consuming dietary iron, the nurse asks him to select iron-rich breakfast items from a sample menu. Which selection demonstrates knowledge of dietary iron sources? a) Ham and eggs b) Bagel and cream cheese c) Grapefruit and white toast d) Pancakes and a banana
Ham and eggs Explanation: Good sources of dietary iron include red meat, egg yolks, whole wheat breads, seafood, nuts, legumes, iron-fortified cereals, and green, leafy vegetables.
Following a precipitous birth, examination of the client's vagina reveals a fourth-degree laceration. Which intervention is appropriate when caring for this client? a) Applying heat to limit edema during the first 12 to 24 hours b) Instructing the client about the importance of perineal (Kegel) exercises c) Instructing the client to use two or more perineal pads to cushion the area d) Instructing the client to avoid using sitz baths if ordered
Instructing the client about the importance of perineal (Kegel) exercises Explanation: Kegel exercises, cold (not heat) applications, and sitz baths are all appropriate interventions for a client with a fourth-degree laceration.
Which intervention is essential when performing dressing changes on a client with a diabetic foot ulcer? a) Using sterile technique during the dressing change b) Cleaning the wound with a povidone-iodine solution c) Debriding the wound three times per day d) Applying a heating pad
Remove elastic stockings once per day and observe lower extremities. Explanation: Elastic stockings are used to promote venous return and prevent deep vein thrombosis. A client with peripheral vascular disease and diabetes is at risk for skin breakdown, and the nurse must therefore remove the stockings once per day to observe the condition of the skin
When caring for a client who has had a cesarean birth, which action by a nurse requires intervention? a) Monitoring pain status and providing necessary relief b) Assisting with parent-neonate bonding c) Removing the initial dressing for incision inspection d) Supporting self-esteem concerns about the birth
Removing the initial dressing for incision inspection Correct Explanation: Nursing care should never include removing the initial dressing put on in the operating room. Appropriate nursing care for the incision would include circling any drainage, reporting findings to the physician, and reinforcing the dressing as needed.
A nurse is evaluating a client's auditory function. To compare air conduction to bone conduction, the nurse should conduct which test? a) Whispered voice test b) Watch tick test c) Weber's test d) Rinne test
Rinne test Correct Explanation: The Rinne test compares air conduction to bone conduction in both ears. The whispered voice test evaluates low-pitched sounds, and the watch tick test assesses high-pitched sounds. Both tests assess gross hearing. Weber's test evaluates bone conduction
A nurse is instructing the client to do Kegel exercises. What should the nurse tell the client to do to perform these pelvic floor exercises? a) Lift both legs while lying down. b) Do pelvic squats. c) Tighten her stomach muscles. d) Stop the flow of urine while urinating.
Stop the flow of urine while urinating. Correct Explanation: By stopping urine flow during urination, the pelvic floor muscles are contracted.
Which of the following expected outcomes would be appropriate for the client who has ulcerative colitis? The client: a) Maintains a daily record of intake and output. b) Uses a heating pad to decrease abdominal cramping. c) Accepts that a colostomy is inevitable at some time in his life. d) Verbalizes the importance of small, frequent feedings.
Verbalizes the importance of small, frequent feedings. Explanation: Small, frequent feedings are better tolerated by clients with ulcerative colitis as they lessen the amount of fecal material present in the gastrointestinal tract and decrease stimulation.
A nurse is caring for a severely depressed client who is barely functioning. The priority nursing goal for this client would be to: a) assess for level of depression and continue antidepressant medication. b) assess for and maintain adequate nutrition and hydration. c) assess for the client's hygiene needs and ensure that these needs are met. d) involve the client's family in his care as much as possible.
assess for and maintain adequate nutrition and hydration. Explanation: Food and fluid intake may be compromised in a client who is severely depressed. The nurse must ensure that the client is adequately hydrated and is receiving proper nutrition
A client in labor asks the nurse about Reiki, an alternative therapy that she's heard may be useful during the intrapartum period. The nurse tells the client that Reiki is based on the principle of: a) vigorous massage. b) energy from light touch. c) energy from a light source. d) mind-body control.
energy from light touch. Correct Explanation: Reiki is based on the principle that energy from hands being placed lightly on or at a distance from the body can be used to heal.
A breastfeeding primiparous client asks the nurse how breast milk differs from cow's milk. The nurse responds by saying that breast milk is higher in which nutrient? a) calcium b) sodium c) iron d) fat
fat Correct Explanation: Breast milk has a higher fat content than cow's milk. Thirty to fifty-five percent of the calories in breast milk are from fat. Breast milk contains less iron than cow's milk does. However, the iron absorption from breast milk is greater in the neonate than with cow's milk. Breast milk contains less sodium and calcium than cow's milk
Which diet would be most appropriate for the client with ulcerative colitis? a) high-calorie, low-protein b) low-fat, high-fiber c) high-protein, low-residue d) low-sodium, high-carbohydrate
high-protein, low-residue Correct Explanation: Clients with ulcerative colitis should follow a well-balanced high-protein, high-calorie, low-residue diet, avoiding such high-residue foods as whole-wheat grains, nuts, and raw fruits and vegetables. Clients with ulcerative colitis need more protein for tissue healing and should avoid excess roughage.
A hospitalized client is experiencing a "fight-versus-flight," a stress-mediated physiologic response. As a result, the nurse should assess the client for: a) increased urinary output. b) decreased mental acuity. c) increased blood glucose. d) decreased arterial blood pressure.
increased blood glucose. Correct Explanation: Responses to physiologic stress, such as hospitalization, surgery, or pain, are a result of catecholamine release, and specifically include increased heart rate and blood pressure, increased bronchiolar dilation, water retention and decreased urinary output, increased blood glucose, and increased mental acuity
A nurse must apply an elastic bandage to a client's ankle and calf. She should apply the bandage beginning at the client's: a) knee. b) lower foot. c) lower thigh. d) ankle.
lower foot. Correct Explanation: An elastic bandage should be applied from the distal area to the proximal area. This method promotes venous return. In this case, the nurse should begin applying the bandage at the client's foot. Beginning at the ankle, lower thigh, or knee will not promote venous return
A 5-year-old child with burns on the trunk and arms has no appetite. The nurse and parent develop a plan of care to stimulate the child's appetite. Which suggestion made by the parent would indicate the need for additional teaching? a) deciding that the parent will feed the child b) serving smaller and more frequent meals c) offering the child finger foods that the child likes d) withholding dessert and treats unless meals are eaten
withholding dessert and treats unless meals are eaten Explanation: Withholding certain foods until the child complies is punitive and rarely successful.
The client who experiences angina has been told to follow a low-cholesterol diet. Which meal would be best? a) spaghetti with tomato sauce, salad, and coffee b) fried chicken, green beans, and skim milk c) hamburger, salad, and milkshake d) baked liver, green beans, and coffee
spaghetti with tomato sauce, salad, and coffee Correct Explanation: Pasta, tomato sauce, salad, and coffee would be the best selection for the client following a low-cholesterol diet.
When examining a client who has abdominal pain, a nurse should assess: a) the symptomatic quadrant first. b) the symptomatic quadrant either second or third. c) any quadrant first. d) the symptomatic quadrant last.
the symptomatic quadrant last. Correct Explanation: The nurse should systematically assess all areas of the abdomen, if time and the client's condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This tightening would interfere with further assessment.
A primigravid client at 32 weeks' gestation is enrolled in a breast-feeding class. Which statements indicate that the client understands the breast-feeding education? Select all that apply. a) "I can hold my baby several different ways during feedings." b) "If I breast-feed, my uterus will return to prepregnancy size more quickly." c) "If my infant latches on properly, I will not develop mastitis." d) "My milk supply will be adequate since I have increased a whole bra size during pregnancy." e) "I need to feed my baby when I see feeding cues and not wait until she is crying."
• "I need to feed my baby when I see feeding cues and not wait until she is crying." • "If I breast-feed, my uterus will return to prepregnancy size more quickly." • "I can hold my baby several different ways during feedings." Correct Explanation: Understanding of breast-feeding education is demonstrated by statements involving knowledge of the several positions available for comfortable breast-feeding, oxytocin release from the pituitary leading to a let-down reflex and uterine contractions for involution, and feeding cues helpful in successful breast-feeding (because waiting until the infant is hungry and crying is stressful).
A 7-year-old client is admitted to the hospital for a tonsillectomy. After the surgery, the physician orders a clear liquid diet. The nurse is correct in giving the child which items? Select all that apply. a) Ice cream b) Lime gelatin c) Orange juice d) Cream of chicken soup e) Chicken broth f) Apple juic
• Apple juice • Chicken broth • Lime gelatin Correct Explanation: Clear liquids include clear broth, gelatin, clear juices, water, and ice chips
A nurse is preparing a delusional client for a computed tomography scan of the brain to rule out an organic etiology. As the nurse accompanies the client to the radiology department, he looks around anxiously and states, "The Interpol is coming to kill me." What is the nurse's best response? a) "It sounds like you're frightened." b) "Your illness is causing you to hear voices." c) "The Interpol isn't here." d) "No one can hurt you here."
"It sounds like you're frightened." Correct Explanation: Even though the client's thinking processes are distorted and irrational, his feelings are very real. The nurse should intervene by empathizing with his emotions
On the second postpartum day after a cesarean birth, the client reports having gas pains. The nurse should instruct the client to do which of the following? a) Chew on some ice chips. b) Drink some hot coffee. c) Ambulate more often. d) Ask the primary care provider for a simethicone prescription.
Ambulate more often. Correct Explanation: During the first few days postpartum, the accumulation of gas in the intestines may cause discomfort. This is relieved by measures such as increasing activity, doing leg exercises, avoiding carbonated or very hot or cold beverages, avoiding using ice or straws, and maintaining a high-protein liquid diet for the first 24 to 48 hours
When inspecting a client's skin, a nurse finds a circumscribed elevated area filled with serous fluid. What term should the nurse use to document this finding? a) Papule b) Pustule c) Vesicle d) Macule
Vesicle Correct Explanation: A vesicle is a circumscribed skin elevation filled with serous fluid. A flat, nonpalpable, colored spot is a macule. A solid, elevated, circumscribed lesion is a papule. An elevated, pus-filled, circumscribed lesion is a pustule.
The nurse is developing a care plan for a client with an episiotomy. Which interventions would be included for the nursing diagnosis Acute pain related to perineal sutures? Select all that apply. a) Limit the number of times the perineal pad is changed. b) Apply an ice pack intermittently to the perineal area for 3 days. c) Encourage the client to do Kegel exercises. d) Administer sitz baths three to four times per day. e) Avoid the application of topical pain gels.
• Encourage the client to do Kegel exercises. • Administer sitz baths three to four times per day. Correct Explanation: Sitz baths help decrease inflammation and tension in the perineal area. Kegel exercises improve circulation to the area and help reduce edema.
Which recommendation would be most helpful to suggest to a primigravid client at 37 weeks' gestation who has leg cramps? a) Straighten the knee and flex the toes toward the chin. b) Lie prone in bed with the legs elevated. c) Alternately flex and extend the legs. d) Change positions frequently throughout the day.
Straighten the knee and flex the toes toward the chin. Explanation: Leg cramps are thought to result from excessive amounts of phosphorus absorbed from milk products. Straightening the knee and flexing the toes toward the chin is an effective measure to relieve leg cramps. Also, decreasing milk intake and supplementing with calcium lactate may help to reduce the cramping.
The health care provider (HCP) has ordered a sterile urine specimen on a 3-year-old boy with a history of recurrent urinary tract infections. The family is upset because the last time the child was catheterized the procedure was very painful and traumatic. The nurse should tell the family: a) "I will get a prescription for a lubricant with numbing medicine to make the procedure more comfortable." b) "I will request a prescription for a sedative to help him relax." c) "I can apply a topical anesthetic 20 minutes before placing the catheter." d) "I cannot do anything to reduce the pain, but you can hold him during the procedure."
"I will get a prescription for a lubricant with numbing medicine to make the procedure more comfortable." Correct Explanation: Two percent lidocaine lubricants have been found to significantly reduce the pain of urinary catheter insertion in children. If the unit does not have a standing protocol to use the lubricant, the nurse should request a prescription.
A client who suffered blunt chest trauma in a motor vehicle accident complains of chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse detects a pericardial friction rub — a classic sign of acute pericarditis. The physician confirms acute pericarditis and begins appropriate medical intervention. To relieve chest pain associated with pericarditis, which position should the nurse encourage the client to assume? a) Supine b) Semi-Fowler's c) Leaning forward while sitting d) Prone
Leaning forward while sitting Correct Explanation: The nurse should encourage the client to lean forward, because this position causes the heart to pull away from the diaphragmatic pleurae of the lungs, helping relieve chest pain caused by pericarditis.
A client comes to the clinic for a routine checkup. To assess the client's gag reflex, the nurse should use which method? a) Place a tongue blade on the uvula. b) Place a tongue blade on the middle of the tongue and ask the client to cough. c) Place a tongue blade on the front of the tongue and ask the client to say "ah." d) Place a tongue blade lightly on the posterior aspect of the pharynx.
Place a tongue blade lightly on the posterior aspect of the pharynx. Correct Explanation: To assess a client's gag reflex, the nurse should gently touch the posterior aspect of the pharynx with a tongue blade, which should elicit gagging.
The nurse is teaching the mother of a newly diagnosed diabetic child about the principles of the diabetic diet. Which of the following statements by the mother indicates effective teaching? a) "Snacks are used to keep blood glucose at acceptable levels during times when the insulin level peaks." b) "By spreading the calories throughout the day in small, frequent meals, the risk of hyperglycemia is eliminated." c) "Snacks are used to offset the desire for sweets and to keep the meals smaller so my child can eat better." d) "Most children find it difficult to eat all the calories required by their diets in three main meals."
"Snacks are used to keep blood glucose at acceptable levels during times when the insulin level peaks." Explanation: Snacks are included in the diabetic diet to offset periods of peak insulin action. Because of the lack of pancreatic functioning, the child does not receive differing amounts of insulin in response to the glucose level in the bloodstream. The child with diabetes mellitus is given insulin at specific times; dietary intake must be matched to the insulin peaks and troughs.
The nurse is teaching the mother of a newly diagnosed diabetic child about the principles of the diabetic diet. Which of the following statements by the mother indicates effective teaching? a) "Snacks are used to offset the desire for sweets and to keep the meals smaller so my child can eat better." b) "Snacks are used to keep blood glucose at acceptable levels during times when the insulin level peaks." c) "Most children find it difficult to eat all the calories required by their diets in three main meals." d) "By spreading the calories throughout the day in small, frequent meals, the risk of hyperglycemia is eliminated."
"Snacks are used to keep blood glucose at acceptable levels during times when the insulin level peaks." Correct Explanation: Snacks are included in the diabetic diet to offset periods of peak insulin action. Because of the lack of pancreatic functioning, the child does not receive differing amounts of insulin in response to the glucose level in the bloodstream. The child with diabetes mellitus is given insulin at specific times; dietary intake must be matched to the insulin peaks and troughs.
The client with tuberculosis is to be discharged home with nursing follow-up. Which aspect of nursing care will have the highest priority? a) assessing the client's environment for sanitation b) coordinating various agency services c) teaching the client about the disease and its treatment d) offering the client emotional support
teaching the client about the disease and its treatment Explanation: Ensuring that the client is well educated about tuberculosis is the highest priority. Education of the client and family is essential to help the client understand the need for completing the prescribed drug therapy to cure the disease.
A 4-year-old has just returned from surgery. He has a nasogastric (NG) tube in place and is attached to intermittent suction. The child says to the nurse, "I'm going to throw up." What should the nurse do first? a) Irrigate the NG tube to ensure patency. b) Encourage the mother to calm the child down. c) Immediately give the child an antiemetic I.V. d) Notify the physician because the child has an NG tube.
Irrigate the NG tube to ensure patency. Correct Explanation: The nurse should first irrigate the NG tube because if the tube isn't draining properly or is kinked, the child will experience nausea.
The nurse is caring for a full-term, nonmedicated, primiparous client who is in the transition stage of labor. The client is writhing in pain and saying, "Help me, help me!" Her last vaginal exam 1 hour ago showed that she was 8 cm dilated, +1 station, and in what appeared to be a comfortable position. What does the nurse anticipate as the highest priority intervention in caring for this client? a) Perform a vaginal examination to determine if the client is fully dilated. b) Ask the client for suggestions to make her more comfortable. c) Help the client through contractions until a narcotic can be given. d) Palpate the bladder to see if it has become distended.
Perform a vaginal examination to determine if the client is fully dilated. Correct Explanation: Transition is the most difficult period of the labor process, and often when clients are tired, pain becomes more intensified. Clients during this stage verbalize anger and are outspoken and difficult to comfort. The most logical next step would be to determine if the client has completed transition and is ready to begin pushing. Performing a vaginal exam would provide this answer.
A nurse is evaluating a client's auditory function. To compare air conduction to bone conduction, the nurse should conduct which test? a) Whispered voice test b) Rinne test c) Weber's test d) Watch tick test
Rinne test Correct Explanation: The Rinne test compares air conduction to bone conduction in both ears. The whispered voice test evaluates low-pitched sounds, and the watch tick test assesses high-pitched sounds. Both tests assess gross hearing. Weber's test evaluates bone conduction.
