Basic Care and Comfort

Question 1

A nurse is repositioning a client who is immobile and at risk for pressure ulcers. Which action best demonstrates correct repositioning technique?

Accepted Answer

Reposition the client every 2 hours using a draw sheet to reduce friction

Answer

Repositioning every 2 hours is the standard to relieve pressure and prevent skin breakdown. A draw sheet reduces friction and shear forces during turning. Donut cushions are contraindicated as they concentrate pressure on surrounding tissue.

Question 2

A client with dysphagia following a stroke is about to receive oral medications. What is the nurse's priority action?

Accepted Answer

Verify with the pharmacist which medications can be crushed before administering

Answer

The nurse must confirm with pharmacy which medications are safe to crush, as some (extended-release, enteric-coated) cannot be altered. Crushing incompatible tablets can alter drug absorption and cause adverse effects.

Question 3

A nurse is performing oral hygiene for an unconscious client. Which intervention is most important to prevent aspiration?

Accepted Answer

Turn the client's head to the side and use suction equipment at the bedside

Answer

Turning the head to the side uses gravity to prevent fluid from flowing toward the airway. Suction must be available immediately to remove secretions. Supine positioning increases aspiration risk, and oral care should be performed every 2 to 4 hours.

Question 4

A postoperative client reports pain of 7 out of 10 and requests a back rub. The nurse administers the prescribed analgesic and then provides the back rub. What principle does this reflect?

Accepted Answer

Complementary comfort measures can be used alongside pharmacological pain management

Answer

Non-pharmacological interventions such as massage, repositioning, and relaxation techniques complement, rather than replace, pharmacological analgesia. Using both together provides more effective pain relief than either alone.

Question 5

A nurse is caring for a client on complete bed rest. Which finding requires the most immediate intervention?

Accepted Answer

The client's calf is tender, warm, and swollen compared to the other leg

Answer

Unilateral calf tenderness, warmth, and swelling are classic signs of deep vein thrombosis (DVT), a life-threatening complication of immobility. The nurse must notify the provider immediately and avoid massaging the leg, as this can dislodge a clot.

NCLEX Practice Test

NCLEX Practice Test

Basic Care and Comfort