Basic Care and Comfort 1 — Questions and Answers
Question 1: A nurse is repositioning a client who is immobile and at risk for pressure ulcers. Which action best demonstrates correct repositioning technique?
- Turn the client every 4 hours and use a donut cushion under the coccyx
- Reposition the client every 2 hours using a draw sheet to reduce friction (Correct answer)
- Keep the head of bed elevated at 60 degrees at all times to prevent aspiration
- Place the client in the same position each time to maintain consistency
Correct answer: Reposition the client every 2 hours using a draw sheet to reduce friction
Repositioning every 2 hours is the standard to relieve pressure and prevent skin breakdown. A draw sheet reduces friction and shear forces during turning. Donut cushions are contraindicated as they concentrate pressure on surrounding tissue.
Question 2: A client with dysphagia following a stroke is about to receive oral medications. What is the nurse's priority action?
- Crush all medications and mix them with applesauce without checking compatibility
- Hold all medications until the client can swallow normally
- Verify with the pharmacist which medications can be crushed before administering (Correct answer)
- Administer medications with a large sip of water to help them go down
Correct answer: Verify with the pharmacist which medications can be crushed before administering
The nurse must confirm with pharmacy which medications are safe to crush, as some (extended-release, enteric-coated) cannot be altered. Crushing incompatible tablets can alter drug absorption and cause adverse effects.
Question 3: A nurse is performing oral hygiene for an unconscious client. Which intervention is most important to prevent aspiration?
- Use a large volume of water to rinse the mouth thoroughly
- Position the client supine and tilt the head back
- Turn the client's head to the side and use suction equipment at the bedside (Correct answer)
- Perform oral care only once per shift to minimize stimulation
Correct answer: Turn the client's head to the side and use suction equipment at the bedside
Turning the head to the side uses gravity to prevent fluid from flowing toward the airway. Suction must be available immediately to remove secretions. Supine positioning increases aspiration risk, and oral care should be performed every 2 to 4 hours.
Question 4: A postoperative client reports pain of 7 out of 10 and requests a back rub. The nurse administers the prescribed analgesic and then provides the back rub. What principle does this reflect?
- Non-pharmacological measures replace analgesic therapy when used together
- Complementary comfort measures can be used alongside pharmacological pain management (Correct answer)
- Back rubs are only appropriate for clients with mild pain scores below 4
- The nurse should have provided the back rub before giving any medication
Correct answer: Complementary comfort measures can be used alongside pharmacological pain management
Non-pharmacological interventions such as massage, repositioning, and relaxation techniques complement, rather than replace, pharmacological analgesia. Using both together provides more effective pain relief than either alone.
Question 5: A nurse is caring for a client on complete bed rest. Which finding requires the most immediate intervention?
- The client's calf is tender, warm, and swollen compared to the other leg (Correct answer)
- The client requests a softer pillow for comfort
- The client's heels appear slightly reddened but blanch with pressure
- The client reports mild lower back stiffness after lying in bed all morning
Correct answer: The client's calf is tender, warm, and swollen compared to the other leg
Unilateral calf tenderness, warmth, and swelling are classic signs of deep vein thrombosis (DVT), a life-threatening complication of immobility. The nurse must notify the provider immediately and avoid massaging the leg, as this can dislodge a clot.
Question 6: A nurse is assisting a client with activities of daily living (ADLs). The client has left-sided weakness following a stroke. When helping the client dress, the nurse should:
- Dress the right (strong) arm first, then thread the left arm through the sleeve
- Dress the left (weak) arm first, then thread the right arm through the sleeve (Correct answer)
- Complete all dressing for the client to reduce the risk of injury
- Allow the client to attempt dressing independently regardless of safety
Correct answer: Dress the left (weak) arm first, then thread the right arm through the sleeve
When dressing a client with one-sided weakness, the affected (weak) limb is dressed first because it has limited range of motion and flexibility. The unaffected limb is threaded through last. This technique reduces discomfort and joint stress.
Basic Care and Comfort 1
A nurse is repositioning a client who is immobile and at risk for pressure ulcers.
Which action best demonstrates correct repositioning technique?