CPNRE Basic Care 4 — Questions and Answers
Question 1: A client with a nasogastric tube is receiving continuous enteral feeding. Which nursing action is the highest priority?
- Verify tube placement every 4 hours by checking gastric pH
- Elevate the head of the bed to at least 30-45 degrees (Correct answer)
- Flush the tube with 30 mL of water every 8 hours
- Warm the formula to room temperature before administration
Correct 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.
Question 2: A nurse is removing a client's indwelling urinary catheter. What is the correct sequence of steps?
- Deflate balloon, then withdraw catheter slowly (Correct answer)
- Withdraw catheter, then deflate balloon
- Clamp catheter, deflate balloon, then withdraw
- Deflate balloon, clamp catheter, then withdraw
Correct answer: Deflate balloon, then withdraw catheter slowly
The balloon must be fully deflated before withdrawing the catheter to prevent urethral trauma.
Question 3: A client reports difficulty sleeping due to pain. After administering ordered analgesics, which additional non-pharmacological measure should the nurse implement first?
- Offer a warm, non-caffeinated beverage
- Dim the lights and reduce environmental noise (Correct answer)
- Encourage light exercise before bed
- Provide a heating pad to the painful area
Correct 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.
Question 4: When performing a bed bath, a nurse should wash the client's body in which order?
- Face, neck, chest, arms, abdomen, legs, perineum, back (Correct answer)
- Face, arms, chest, abdomen, legs, back, perineum, neck
- Perineum, legs, abdomen, chest, arms, neck, face, back
- Back, face, chest, arms, abdomen, legs, perineum, neck
Correct 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.
Question 5: 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?
- Encourage increased oral fluid intake
- Palpate and percuss the suprapubic area to assess for bladder distension (Correct answer)
- Insert an indwelling urinary catheter immediately
- Notify the physician before performing any assessment
Correct 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.
Question 6: A client on bed rest develops redness over the sacrum that blanches when pressed. How should the nurse document and classify this finding?
- Stage II pressure injury with skin breakdown
- Stage I pressure injury with intact skin (Correct answer)
- Suspected deep tissue injury
- Unstageable pressure injury
Correct 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.
Question 7: A nurse is assisting a client with oral hygiene. The client is unconscious. Which action is most important to prevent aspiration?
- Use a large-volume syringe to rinse the mouth thoroughly
- Position the client in a lateral (side-lying) position with head lowered (Correct answer)
- Apply a thick layer of lip balm after oral care
- Brush teeth vigorously to remove all debris
Correct 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.
CPNRE Basic Care 4
A client with a nasogastric tube is receiving continuous enteral feeding.
Which nursing action is the highest priority?