Basic Care Flashcards

A client with a nasogastric tube is receiving continuous enteral feeding. Which nursing action is the highest priority?

Answer: Elevate the head of the bed to at least 30-45 degrees

Elevating the head of the bed to 30-45 degrees is the highest priority to prevent aspiration pneumonia in clients receiving enteral feedings.

A nurse is removing a client's indwelling urinary catheter. What is the correct sequence of steps?

Answer: Deflate balloon, then withdraw catheter slowly

The balloon must be fully deflated before withdrawing the catheter to prevent urethral trauma.

A client reports difficulty sleeping due to pain. After administering ordered analgesics, which additional non-pharmacological measure should the nurse implement first?

Answer: Dim the lights and reduce environmental noise

Reducing environmental stimuli by dimming lights and minimizing noise creates a restful environment that promotes sleep onset.

When performing a bed bath, a nurse should wash the client's body in which order?

Answer: Face, neck, chest, arms, abdomen, legs, perineum, back

Washing from the cleanest areas (face) to the least clean (perineum) prevents cross-contamination and reduces infection risk.

A nurse is caring for a postoperative client who has not voided in 8 hours. The client reports lower abdominal discomfort. What is the nurse's priority action?

Answer: Palpate and percuss the suprapubic area to assess for bladder distension

Assessing for bladder distension by palpation and percussion confirms urinary retention before any intervention is initiated.

A client on bed rest develops redness over the sacrum that blanches when pressed. How should the nurse document and classify this finding?

Answer: Stage I pressure injury with intact skin

Redness that blanches indicates intact skin with a reactive hyperemic response, classified as a Stage I pressure injury.

A nurse is assisting a client with oral hygiene. The client is unconscious. Which action is most important to prevent aspiration?

Answer: Position the client in a lateral (side-lying) position with head lowered

Positioning an unconscious client in a lateral, head-down position allows fluids to drain out of the mouth rather than into the airway.