Basic Care and Comfort 2

Question 1

A nurse is caring for a client who has been on bed rest for 5 days. Which intervention is the highest priority to prevent complications?

Accepted Answer

Reposition the client every 2 hours

Answer

Repositioning every 2 hours is the highest priority to prevent pressure injuries, which are a major complication of immobility. All other interventions are also important but pressure ulcer prevention is the most immediate concern.

Question 2

A nurse is assisting a post-operative client with the first ambulation after hip replacement surgery. Which action should the nurse take first?

Accepted Answer

Have the client dangle legs at the side of the bed

Answer

Dangling the legs at the side of the bed before standing allows the client's blood pressure to equilibrate and reduces the risk of orthostatic hypotension. This is the correct first step before attempting to stand.

Question 3

A nurse is caring for a client receiving nasogastric tube feedings. Which action should the nurse take before initiating the feeding?

Accepted Answer

Verify tube placement by checking gastric pH

Answer

Verifying nasogastric tube placement before initiating any feeding is the priority safety action to prevent aspiration. Checking aspirate pH (should be 4 or less for gastric placement) confirms the tube is in the stomach.

Question 4

A nurse is providing oral hygiene for an unconscious client. Which action is most important to prevent aspiration?

Accepted Answer

Position the client in a lateral (side-lying) position

Answer

Positioning the unconscious client in a lateral (side-lying) position allows fluids to drain from the mouth by gravity rather than pooling in the posterior pharynx, significantly reducing the risk of aspiration.

Question 5

A nurse is assessing a client for pain using a numeric rating scale. The client rates their pain as 8 out of 10. Which intervention should the nurse implement first?

Accepted Answer

Administer the prescribed analgesic medication

Answer

A pain rating of 8/10 indicates severe pain. The nurse should administer the prescribed analgesic first to provide timely relief, as pain management is a priority nursing intervention.

NCLEX Practice Test

NCLEX Practice Test

Basic Care and Comfort 2