FREE NCLEX-RN Basic Care & Comfort Questions and Answers
The nurse is giving advice to a patient who will soon undergo surgery to remove a descending colostomy. What kind of stools might the patient anticipate following surgery?
Due to the fact that a large portion of the water has already been absorbed, the stool from a descending or sigmoid colostomy is semi-formed to form. The stool does not contain caustic enzymes and is harder than that after a transverse colostomy. After a certain volume of feces has accumulated in the colon above the colostomy, elimination may happen at regular, predictable intervals. There is no anus to keep the bowel movement contained, therefore spilling might occur in between. For security, many people opt to wear a small, disposable pouch.
The nurse brings an Orthodox Jewish customer a dinner tray. A cheeseburger with lettuce and tomato, French fries, a fruit salad, and a vanilla milkshake are all included on the tray. Which of the nurse's actions is BEST?
The nurse needs to take the tray away and ask for the client to have a new Kosher dinner. Judaism has specific rules for the preparation and serving of food. Kosher refers to food that is permitted. "Treif" is the term for food that is prohibited. Orthodox Jews strictly adhere to the dietary regulations because they believe it shows obedience and restraint. Land animals must have split hooves and chew cud. Porks do not. Shellfish is not allowed as seafood since it needs to have fins and scales. Dairy and meat cannot be served on the same plate or consumed at the same time.
The nurse is giving parents of a 3-year-old who was admitted to the hospital with severe croup guidelines for release. What non-pharmaceutical measures can parents take at home in the event of a subsequent croup attack?
Parents should create steam in a closed bathroom by running a hot bath or shower if their child has croup at home. The youngster can then be brought inside the steamy space and allowed to breathe the damp, humid air. This will mobilize and liquefy secretions. The parent should reassure the youngster while holding the child upright. Secretions cannot be loosened in a dry environment. Hypoxia can be aggravated and made worse by crying.
Right lower lobe (RLL) pneumonia has been identified in a pediatric child who has been admitted to the unit. What noise ought the nurse to listen for when auscultating the RLL?
Most likely, crackles would be audible since they would indicate the presence of fluid in the air. Pneumonia is likely if there is fluid in the airways. A constriction of the airways is indicated by wheezes. Airways that are constricted can produce the emergency lung sound known as stridor, which can result in full airway closure. Rhonchi can be heard when there are both secretions and constricted airways.
A patient is in an awkward position in her bed when the nurse enters the room to inject insulin. What should the nurse start by doing?
The patient's comfort is the nurse's top priority. The nurse can check the patient's ID bracelet and ask the patient for her name when the patient has been properly adjusted. The insulin may then be given by the nurse.
Which positioning is ideal for the client before to a soap suds enema?
The client must be in the Sims position in order to receive an enema. The patient is lying on their left side with their right leg out in front of them. The rectum and colon can more easily receive the enema fluid when you are in this position. The supine position involves resting flat with the torso and face upward. The prone position involves lying flat on one's back with the head and torso down. The lithotomy position is resting on one's back with their legs and hips 90 degrees bent.
Congestive heart failure (CHF) patients must follow rigorous intake and output (I&O) guidelines with daily weights. The client's intake was 2200 mL, and their output was 1200 mL throughout the 24-hour I&O, according to the nurse. What would the probable next daily weight be?
The client's weight should rise by 2.2 pounds, according to the nurse. Kilograms and liters of fluid both weigh 2.2 pounds per unit. To compute: 1. 2200mL minus 1200mL equals 1000mL. 2. 1000 mL equals 1 liter 3. One liter weighs 2.2 pounds.
A nasogastric (NG) tube is used by one of the nurse's patients to provide medications and for tube feedings. Which nursing intervention is suitable for this patient's care?
Every day, the nurse should replace the tape at the patient's nose and check the skin for deterioration. Every 24 hours, feeding equipment and tubing are replaced. Warm water is used to flush out the NG tube to prevent burning or pain to the patient. For tube feedings, the bed is positioned in the high Fowler's position.
A young client with leukemia is having nausea and vomiting as a result of chemotherapy. Which of the following foods will be the BEST at now supplying enough nutrition?
The frequent side effects of chemotherapy regimens include nausea and vomiting. The child's health care provider (HCP) will be given an antiemetic prescription. The youngster might not feel like eating, though, and may still feel queasy. Small meals and frequent sips of liquids can be beneficial. The finest foods are frequently those that are cold and have little to no smell. Fruit juice, fruit puree, and cold desserts are a few examples. High-calorie, high-protein foods can be served once the nausea has subsided.
A patient with primary adrenal insufficiency (Addison's disease) is receiving education from the nurse regarding dietary and nutritional adjustments necessary to manage the client's condition. Which of the following statements made by the patient would suggest that the nurse's recommendations were successful?
Damage to the adrenal glands leads to the development of Addison's disease. The hormones cortisol and aldosterone are not produced in sufficient amounts. In addition to corticosteroid drugs, dietary modifications include more sodium, less potassium, and enough fluid intake.
A patient requests the nurse's advice on a breakfast that can aid with constipation prevention during a normal check-up. Which of the following food options would be the best?
On a 2,000-calorie diet, the American Heart Association advises adults to consume 25–30 grams of fiber daily from dietary sources (not supplements). Almost equal amounts of soluble and insoluble dietary fiber are present in oats' 5 grams of fiber. Raspberries have 8 grams of fiber, compared to 3 to 4 grams in apples, bananas, oranges, and strawberries. There are 4 grams of fiber in a plain bagel and 4 grams in cream cheese. There are no grams of fiber in eggs or bacon. The amount of fiber in an orange juice glass is 0.2 grams, compared to 0.8 grams in a doughnut.
A expectant client makes her first visit to the prenatal clinic. This is the client's third pregnancy, the nurse observes. She gave birth to a healthy boy four years ago at 38 weeks, and a healthy girl two years ago at 35 weeks. The nurse will document the client's obstetrical history using the gravida/para method.
A nurse should record Gravida 3 - Para 2 using the gravida/para system. The customer is expecting her third child (Gravida 3), and her previous two pregnancies lasted more than 20 weeks each (Para 2). The alternate choices are false.
Which step is most appropriate when providing postmortem care for a patient who will donate an eye?
Close the eyelids and cover them with moistened gauze pads while preparing a deceased patient for corneal or eye donation. If you can, place a small ice pack over your eyes. The eyes will stay closed if the bed's head is raised.
Which of the following assessment results is in line with a volume deficit of extracellular fluid?
Oliguria is a symptom of inadequate extracellular fluid volume. The bodily fluid that isn't housed inside of individual cells is known as extracellular fluid. It includes spinal cord fluid, lymph, blood plasma, and intercellular fluid, and makes up around 20% of our body weight. It's important to note that this fluid contains electrolytes in addition to water and other necessary solutes. Oliguria frequently results from blood loss, vomiting, diarrhea, polyuria, profuse perspiration, and burns. The other possible answers have nothing to do with fluid deficiency or hypovolemia.
A vegetarian client is being instructed by the nurse in the prenatal clinic on how to prevent iron deficiency anemia while pregnant. Which food selection made by the client suggests that more teaching is required?
Vegans in particular need to consume twice as much iron as non-vegetarians do. The form of iron included in cereals, lentils, vegetables, and fruits—non-heme iron—is not as easily absorbed as heme iron. Additionally, vegans frequently have lower iron stores than meat-eaters do. Premature delivery and a smaller birth weight for the child are both risks associated with anemia during pregnancy. Additionally, it can lower the amount of iron the baby stores throughout gestation, increasing the likelihood that the child will later develop an iron deficit. Pregnant vegetarians should consume a variety of foods throughout the day that are high in vitamin C and iron. When iron and vitamin C are both ingested, iron's rate of absorption decreases.
What is the appropriate way to respond to a patient at the senior living facility who throws his tray to the ground and yells, "This food is terrible! I can't stand this another minute!"
Try to comprehend the motivations behind a resident's behavior if they act in an out-of-character manner. Avoid being obnoxious or confrontational in your response. Explore the causes of the behavior and present a substitute. It is not about the menu in this instance. To help the client, the nurse should engage in therapeutic conversation.