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

Administer prescribed PRN analgesic immediately

Answer

Apply a heating pad to the lower back for 20 minutes

Answer

Request a physical therapy consultation for tomorrow

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

Encourage the patient to continue walking as dizziness is expected

Answer

Return the patient to bed immediately using a gait belt and calling for assistance

Answer

Ask the patient to hold onto the wall and rest for a moment

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

Warm the formula to body temperature

Answer

Elevate the head of the bed to 15 degrees

Answer

Flush the tube with 60 mL of water

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

Supine with head flat to prevent neck strain

Answer

Semi-Fowler's at 45 degrees with head turned to the side

Answer

Prone position to allow fluids to drain freely

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

The catheter is correctly placed; insert 2 more inches and inflate the balloon

Answer

Increase the patient's fluid intake before retrying

Answer

Rotate the catheter 180 degrees and advance slowly

Question 6

A nurse is caring for a patient with a Stage 2 pressure injury on the coccyx. The wound has minimal serous drainage and no signs of infection. Which dressing is most appropriate?

Accepted Answer

Hydrocolloid dressing changed every 3–5 days

Answer

Dry sterile gauze changed twice daily

Answer

Wet-to-dry saline dressing changed every shift

Answer

Alginate dressing for heavy exudate absorption