Basic Care and Comfort 3 — Questions and Answers
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?
- Administer prescribed PRN analgesic immediately
- Reposition the patient every 2 hours and use pressure-relieving devices (Correct answer)
- Apply a heating pad to the lower back for 20 minutes
- Request a physical therapy consultation for tomorrow
Correct answer: Reposition the patient every 2 hours and use pressure-relieving devices
Repositioning every 2 hours is the priority intervention because it addresses both comfort and prevention of pressure injuries, which are a major complication of prolonged bed rest. This is a fundamental nursing responsibility that does not require a physician order and directly addresses the root cause of the discomfort.
For a patient on prolonged bed rest, repositioning every 2 hours is the gold standard for both comfort and pressure injury prevention. While analgesics may help with pain, they do not address the underlying cause. Heating pads pose a burn risk in immobile patients. Physical therapy is appropriate but not the immediate priority. The nurse's independent role in skin integrity and comfort management makes repositioning the priority action.
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?
- Encourage the patient to continue walking as dizziness is expected
- Return the patient to bed immediately using a gait belt and calling for assistance
- Have the patient sit in the nearest chair and assess vital signs (Correct answer)
- Ask the patient to hold onto the wall and rest for a moment
Correct answer: Have the patient sit in the nearest chair and assess vital signs
Orthostatic hypotension is a common postoperative complication. When a patient reports dizziness and weakness during first ambulation, the safest immediate action is to seat the patient in the nearest stable location (chair) and assess vital signs. This is safer than attempting to walk back to bed and allows immediate assessment of the cause.
The safest response to symptomatic orthostatic hypotension during ambulation is to immediately seat the patient in the nearest chair and assess vital signs. Continuing to ambulate risks a fall. Returning to bed requires more walking and increases fall risk. Having the patient lean against a wall is not sufficiently safe or therapeutic. Seating the patient, assessing vital signs, and monitoring for improvement is the evidence-based approach.
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?
- Warm the formula to body temperature
- Verify tube placement by checking gastric pH and observing for respiratory distress (Correct answer)
- Elevate the head of the bed to 15 degrees
- Flush the tube with 60 mL of water
Correct answer: Verify tube placement by checking gastric pH and observing for respiratory distress
Verifying tube placement before each feeding is the most critical safety step to prevent aspiration pneumonia, which can be life-threatening. Confirming placement via pH testing of aspirate (pH ≤5.5 indicates gastric placement) and observing for respiratory distress is the priority safety check.
Accidental pulmonary placement or tube migration is a life-threatening risk with NG tube feedings. Verifying placement before each feeding using pH testing of aspirate is mandatory. Warming formula is not required and may promote bacterial growth. The head of the bed should be elevated to 30-45 degrees (not 15 degrees). Flushing is done after, not before, verification. Placement verification is the non-negotiable first step.
Question 4: A nurse is providing oral care for an unconscious patient. Which position is most appropriate during this procedure?
- Supine with head flat to prevent neck strain
- Semi-Fowler's at 45 degrees with head turned to the side
- Lateral position with head slightly lower than the body (Correct answer)
- Prone position to allow fluids to drain freely
Correct answer: Lateral position with head slightly lower than the body
The lateral (side-lying) position with the head slightly lower than the body allows secretions and fluids to drain by gravity, reducing the risk of aspiration during oral care in an unconscious patient. This is the safest position to maintain airway protection.
Unconscious patients lack the gag reflex needed to protect the airway. The lateral position with slight Trendelenburg allows gravity to drain secretions away from the airway, preventing aspiration. Supine or semi-Fowler's positions increase aspiration risk. Prone positioning is rarely used in general care and is impractical for oral hygiene. The lateral position is the evidence-based standard for oral care in unconscious patients.
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?
- The catheter is correctly placed; insert 2 more inches and inflate the balloon
- The catheter may be in the vagina; withdraw it, obtain a new sterile catheter, and reattempt (Correct answer)
- Increase the patient's fluid intake before retrying
- Rotate the catheter 180 degrees and advance slowly
Correct answer: The catheter may be in the vagina; withdraw it, obtain a new sterile catheter, and reattempt
In female patients, the catheter is frequently accidentally inserted into the vagina due to anatomical proximity. If urine does not return after appropriate insertion depth, vaginal placement should be suspected. The catheter is now contaminated and must be replaced with a new sterile catheter before reattempting urethral catheterization.
Accidental vaginal insertion is common in female urinary catheterization, especially with poor lighting or patient positioning. The catheter touching vaginal tissue is now contaminated — sterile technique requires discarding it and using a new sterile catheter. Inflating the balloon without confirming urine return risks bladder/urethral trauma. Rotating the catheter does not address misplacement. Some nurses leave the misplaced catheter in the vagina as a landmark while inserting the new one correctly.
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?
- Dry sterile gauze changed twice daily
- Hydrocolloid dressing changed every 3–5 days (Correct answer)
- Wet-to-dry saline dressing changed every shift
- Alginate dressing for heavy exudate absorption
Correct answer: Hydrocolloid dressing changed every 3–5 days
A hydrocolloid dressing is the recommended treatment for a Stage 2 pressure injury with minimal drainage and no infection. It maintains a moist wound environment that promotes healing, reduces pain during dressing changes, and only needs to be changed every 3–5 days, reducing disruption to the healing tissue.
Stage 2 pressure injuries involve partial-thickness skin loss. Evidence-based wound care supports moist wound healing over dry healing. Hydrocolloid dressings provide the ideal moist environment, are self-adherent, protect from external contamination, and require infrequent changes that minimize wound disruption. Dry gauze is no longer recommended. Wet-to-dry dressings cause pain and trauma on removal. Alginate dressings are for heavy exudate — inappropriate for minimal drainage wounds.
Basic Care and Comfort 3
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?