NCSBN - National Council of State Boards of Nursing Basic Care and Comfort Questions and Answers — Questions and Answers
Question 1: A nurse is caring for an older adult client who has been on bed rest for 3 days following hip surgery. The client reports new-onset tenderness and visible swelling in their left calf. What is the nurse's priority action?
- Encourage the client to perform active range-of-motion exercises.
- Massage the affected leg to promote circulation.
- Keep the client's leg elevated on pillows and notify the healthcare provider. (Correct answer)
- Apply a warm, moist compress to the area for 20 minutes.
Correct answer: Keep the client's leg elevated on pillows and notify the healthcare provider.
The client's signs and symptoms (unilateral calf tenderness and swelling) are classic indicators of a potential deep vein thrombosis (DVT), a serious complication of immobility. The priority is to maintain the client on bed rest, elevate the affected limb to promote venous return without dislodging a potential clot, and immediately notify the healthcare provider for further diagnostic evaluation and treatment. Massaging the leg is contraindicated as it could dislodge a thrombus, leading to a pulmonary embolism.
Question 2: A nurse is calculating the total fluid intake for a client during an 8-hour shift. The client consumed 6 oz of juice, 8 oz of water, 4 oz of gelatin, and received 100 mL of intravenous fluids. How many milliliters (mL) should the nurse document as the total intake?
- 540 mL
- 640 mL (Correct answer)
- 440 mL
- 720 mL
Correct answer: 640 mL
To calculate the total intake in milliliters, the nurse must convert ounces to mL (1 oz = 30 mL) and include all sources of fluid. Juice: 6 oz × 30 mL/oz = 180 mL. Water: 8 oz × 30 mL/oz = 240 mL. Gelatin is a clear liquid and counts as intake: 4 oz × 30 mL/oz = 120 mL. IV fluids: 100 mL. The total intake is the sum of these amounts: 180 + 240 + 120 + 100 = 640 mL.
Question 3: Which of the following actions is essential for a nurse to perform to prevent a catheter-associated urinary tract infection (CAUTI) for a client with an indwelling urinary catheter?
- Irrigating the catheter with sterile saline every 12 hours.
- Ensuring the drainage bag is kept below the level of the bladder. (Correct answer)
- Changing the indwelling catheter every 72 hours.
- Disconnecting the catheter from the tubing to obtain a urine sample.
Correct answer: Ensuring the drainage bag is kept below the level of the bladder.
To prevent CAUTI, it is critical to maintain a closed, sterile drainage system and prevent the backflow of urine. Keeping the drainage bag below the level of the bladder uses gravity to ensure urine flows away from the bladder, which minimizes the risk of infection. Routine irrigation and catheter changes are not recommended as they can introduce bacteria into the system. The system should only be opened when necessary, and samples should be collected from the designated port.
Question 4: A nurse is preparing to provide oral hygiene to an unconscious client. To minimize the risk of aspiration, the nurse should place the client in which position?
- Supine with the head of the bed flat.
- High-Fowler's with the head tilted forward.
- Side-lying with the head turned toward the mattress. (Correct answer)
- Prone with a pillow under the abdomen.
Correct answer: Side-lying with the head turned toward the mattress.
The safest position for providing oral care to an unconscious client is side-lying (lateral) with the head turned to the side. This position allows fluids and secretions to drain out of the mouth by gravity, preventing them from pooling in the back of the throat and being aspirated into the lungs.
Question 5: A nurse is creating a plan of care to promote rest and sleep for a client in a busy hospital setting. Which nursing intervention is most effective?
- Offer a caffeinated beverage in the evening to help the client stay awake during the day.
- Encourage a 60-minute nap in the late afternoon.
- Cluster nursing tasks to minimize interruptions during the night. (Correct answer)
- Keep the room brightly lit at all times to ensure client safety.
Correct answer: Cluster nursing tasks to minimize interruptions during the night.
Clustering care activities, such as administering medications, taking vital signs, and performing assessments at the same time, reduces the number of times a client is awakened. This allows for longer periods of uninterrupted sleep, which is crucial for healing and recovery. Caffeinated beverages, long or late naps, and bright lighting can all interfere with the natural sleep-wake cycle.
Question 6: A client is 12 hours postoperative following abdominal surgery and reports a pain level of 7 on a 0-10 scale. The client received an analgesic 2 hours ago. In addition to assessing the need for further medication, which non-pharmacological comfort measure should the nurse implement first?
- Encouraging the client to ambulate briskly in the hallway.
- Assisting the client to a comfortable position using pillows for support. (Correct answer)
- Applying a cold pack directly over the surgical incision.
- Vigorously massaging the abdomen near the incision site.
Correct answer: Assisting the client to a comfortable position using pillows for support.
Proper positioning and the use of pillows to splint the abdomen can significantly reduce muscle tension and pressure on the incision, thereby alleviating pain. This is a safe and effective adjunctive comfort measure. Brisk ambulation may be too strenuous so soon after surgery. Applying a cold pack or massaging near the incision would require a specific provider order and could be contraindicated.
NCSBN - National Council of State Boards of Nursing Basic Care and Comfort Questions and Answers
A nurse is caring for an older adult client who has been on bed rest for 3 days following hip surgery.
The client reports new-onset tenderness and visible swelling in their left calf.
What is the nurse's priority action?