Basic Care and Comfort 2 — Questions and Answers

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?

Encourage the client to perform active range-of-motion exercises
Apply sequential compression devices to the lower extremities
Reposition the client every 2 hours (Correct answer)
Encourage fluid intake of at least 2,000 mL per day

Correct answer: Reposition the client every 2 hours

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.

Prolonged immobility places clients at significant risk for several complications, including pressure injuries (formerly called pressure ulcers or decubitus ulcers), deep vein thrombosis (DVT), pneumonia, and muscle atrophy. Among these, pressure injuries can develop in as little as 1-2 hours when circulation is compromised. Repositioning every 2 hours distributes pressure away from bony prominences such as the sacrum, heels, elbows, and occiput. This allows blood flow to return to compressed tissues before ischemia and necrosis occur. The nurse should also use positioning aids like foam wedges, pillows, and specialty mattresses. While sequential compression devices help prevent DVT, active range-of-motion exercises maintain muscle strength, and fluid intake supports overall health, none of these address the most immediately preventable complication — skin breakdown — which repositioning directly targets. Using the nursing process, the nurse assesses skin integrity with each turn, documents findings, and adjusts the care plan based on risk factors such as incontinence, poor nutrition, and decreased sensation.

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?

Assist the client to a standing position at the bedside
Have the client dangle legs at the side of the bed (Correct answer)
Apply a gait belt around the client's waist
Ensure non-slip footwear is on the client

Correct answer: Have the client dangle legs at the side of the bed

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.

After prolonged bed rest or surgery, post-operative clients are at high risk for orthostatic hypotension — a drop in blood pressure of 20 mmHg systolic or 10 mmHg diastolic when moving from lying to standing. This can cause dizziness, lightheadedness, and falls. Having the client dangle their legs at the side of the bed for several minutes before standing gives the cardiovascular system time to compensate. During this time, the nurse should assess the client for dizziness, pale skin, diaphoresis, or complaints of lightheadedness, all of which indicate orthostatic hypotension. Although applying a gait belt and ensuring non-slip footwear are essential safety measures, they should be done before the client even moves to the edge of the bed, but the immediate safety concern upon sitting up is hemodynamic stability. The dangling position bridges the transition from supine to standing safely. The nurse should never rush a post-operative client to stand and should always have additional staff available for a first ambulation. If the client becomes symptomatic while dangling, they should be returned to a supine position and the physician notified.

Question 3: A nurse is caring for a client receiving nasogastric tube feedings. Which action should the nurse take before initiating the feeding?

Warm the formula to body temperature
Flush the tube with 30 mL of sterile water
Verify tube placement by checking gastric pH (Correct answer)
Raise the head of the bed to 30-45 degrees

Correct answer: Verify tube placement by checking gastric pH

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.

Nasogastric tube misplacement is a serious safety risk. If a feeding tube inadvertently enters the respiratory tract, initiating a feeding can cause aspiration pneumonia or death. Therefore, confirming tube placement before every feeding is an absolute safety requirement. The gold standard for verifying tube placement is radiographic (X-ray) confirmation, typically done after initial insertion. For ongoing verification before feedings, checking the pH of gastric aspirate is the recommended bedside method. Gastric aspirate pH of 4 or less is consistent with correct gastric placement. Intestinal contents have a higher pH (6 or above), and respiratory secretions are typically 7 or above. Old methods such as auscultating air over the stomach or checking tube length markings are no longer considered reliable as the sole method of verification. The nurse should also visually inspect the aspirate color and character. While elevating the head of the bed to 30-45 degrees is important to prevent aspiration during the feeding, it is not the first action. Placement verification must occur before the bed position change or any feeding initiation. Flushing with water is done after confirming placement, not before.

Question 4: A nurse is providing oral hygiene for an unconscious client. Which action is most important to prevent aspiration?

Use a soft-bristled toothbrush
Position the client in a lateral (side-lying) position (Correct answer)
Use a small amount of toothpaste
Suction the oral cavity before beginning care

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

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.

Unconscious clients lack protective airway reflexes such as the gag reflex and the ability to swallow voluntarily, which makes aspiration during oral care a significant risk. The lateral (side-lying) position uses gravity to drain secretions and fluids out of the mouth rather than toward the airway. During oral hygiene, the nurse uses only small amounts of liquid and suctions as needed to remove excess moisture. A Yankauer suction device should be at the bedside. The mouth should be moistened and teeth, gums, and tongue cleaned gently. Suctioning the oral cavity before beginning care is a helpful preparatory step to remove secretions, but it does not provide ongoing protection throughout the procedure. Positioning is the sustained protective measure during the entire intervention. Using a soft-bristled brush prevents trauma to mucous membranes but does not address aspiration risk directly. A small amount of toothpaste is appropriate to minimize excess fluid, but positioning is still the most critical safety intervention. The nurse should maintain the lateral position throughout the procedure and not leave the client supine.

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?

Notify the healthcare provider of the pain rating
Administer the prescribed analgesic medication (Correct answer)
Offer the client a non-pharmacological comfort measure
Ask the client to describe the quality of the pain

Correct answer: Administer the prescribed analgesic medication

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.

Pain is considered the fifth vital sign, and unrelieved severe pain (rated 7-10/10) requires prompt pharmacological intervention. A pain rating of 8/10 indicates the client is experiencing significant suffering that impairs healing, mobility, and overall well-being. If an analgesic has been prescribed, administering it is the priority action. After assessing pain severity, the nurse confirms the order, checks for allergies, assesses the client's last dose and timing, and administers the medication appropriately. The nurse should also reassess pain 30-60 minutes after analgesic administration to evaluate effectiveness. Non-pharmacological measures such as repositioning, ice, heat, guided imagery, or distraction are appropriate adjuncts to pain management, but at a severity level of 8/10, they are unlikely to provide sufficient relief on their own. They should be used in addition to, not instead of, medication for severe pain. Further pain assessment (quality, location, radiation, aggravating/alleviating factors) would be performed as part of a complete pain assessment but is typically done before or during administration of pain relief. Notifying the provider may be needed if pain is uncontrolled or there is no order, but if a PRN or scheduled analgesic is already ordered, the nurse acts on it without delay.

Question 6: A nurse is caring for a client with a urinary catheter in place for 3 days. The client asks why the catheter tubing must always be positioned below the level of the bladder. What is the best explanation?

It prevents the catheter from becoming dislodged
It allows urine to drain by gravity and prevents backflow (Correct answer)
It reduces the risk of catheter-associated pressure injuries
It keeps the drainage bag sterile

Correct answer: It allows urine to drain by gravity and prevents backflow

Keeping the catheter tubing and drainage bag below bladder level allows urine to drain by gravity, which prevents backflow of urine into the bladder — a major cause of urinary tract infections.

Gravity is essential for proper urinary catheter drainage. When the drainage bag or tubing is positioned above the level of the bladder, urine cannot drain downward and may flow backward into the bladder — a phenomenon called reflux. This backflow introduces bacteria from the tubing or bag into the sterile bladder environment, increasing the risk of catheter-associated urinary tract infections (CAUTIs). CAUTIs are among the most common healthcare-associated infections and are largely preventable through proper catheter care. The drainage bag should always hang lower than the bladder, typically on the bed frame or a dedicated stand — never placed on the floor where it could become contaminated. Additional CAUTI prevention strategies include hand hygiene before and after catheter care, maintaining a closed drainage system, keeping the perineal area clean, and avoiding unnecessary catheter use. The catheter should be secured to prevent tension and movement. While positioning does help prevent the tubing from being kinked or compressed under the patient, the primary reason for keeping it below bladder level is ensuring unobstructed gravitational drainage. The drainage bag is not maintained sterile through positioning alone — it becomes a clean system once the catheter is placed.

Basic Care and Comfort 2

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?