Basic Care and Comfort 3

Question 1

A nurse is caring for a 78-year-old patient who has been on bed rest for 5 days. The patient reports pain rated 3/10 in the lower back. Which intervention is the priority to promote comfort and prevent complications?

Accepted Answer

Reposition the patient every 2 hours and use pressure-relieving devices

Answer

Repositioning every 2 hours is the priority intervention because it addresses both comfort and prevention of pressure injuries, which are a major complication of prolonged bed rest. This is a fundamental nursing responsibility that does not require a physician order and directly addresses the root cause of the discomfort.

Question 2

A nurse is assisting a postoperative patient with ambulation for the first time following abdominal surgery. After taking two steps, the patient states, 'I feel dizzy and my legs are weak.' What is the nurse's best action?

Accepted Answer

Have the patient sit in the nearest chair and assess vital signs

Answer

Orthostatic hypotension is a common postoperative complication. When a patient reports dizziness and weakness during first ambulation, the safest immediate action is to seat the patient in the nearest stable location (chair) and assess vital signs. This is safer than attempting to walk back to bed and allows immediate assessment of the cause.

Question 3

A nurse is caring for a patient receiving enteral tube feedings through a nasogastric tube. Before administering the feeding, which action is most important to perform?

Accepted Answer

Verify tube placement by checking gastric pH and observing for respiratory distress

Answer

Verifying tube placement before each feeding is the most critical safety step to prevent aspiration pneumonia, which can be life-threatening. Confirming placement via pH testing of aspirate (pH ≤5.5 indicates gastric placement) and observing for respiratory distress is the priority safety check.

Question 4

A nurse is providing oral care for an unconscious patient. Which position is most appropriate during this procedure?

Accepted Answer

Lateral position with head slightly lower than the body

Answer

The lateral (side-lying) position with the head slightly lower than the body allows secretions and fluids to drain by gravity, reducing the risk of aspiration during oral care in an unconscious patient. This is the safest position to maintain airway protection.

Question 5

A nurse is inserting a urinary catheter for a female patient. After cleaning the urethral meatus and inserting the catheter approximately 2 inches, urine does not return. What is the most likely explanation and appropriate action?

Accepted Answer

The catheter may be in the vagina; withdraw it, obtain a new sterile catheter, and reattempt

Answer

In female patients, the catheter is frequently accidentally inserted into the vagina due to anatomical proximity. If urine does not return after appropriate insertion depth, vaginal placement should be suspected. The catheter is now contaminated and must be replaced with a new sterile catheter before reattempting urethral catheterization.

NCLEX Practice Test

NCLEX Practice Test

Basic Care and Comfort 3