NCSBN - National Council of State Boards of Nursing Basic Care and Comfort 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?

Accepted Answer

Keep the client's leg elevated on pillows and notify the healthcare provider.

Answer

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?

Accepted Answer

640 mL

Answer

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?

Accepted Answer

Ensuring the drainage bag is kept below the level of the bladder.

Answer

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?

Accepted Answer

Side-lying with the head turned toward the mattress.

Answer

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?

Accepted Answer

Cluster nursing tasks to minimize interruptions during the night.

Answer

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.

NCSBN - National Council of State Boards of Nursing Practice Test

NCSBN - National Council of State Boards of Nursing Practice Test

NCSBN - National Council of State Boards of Nursing Basic Care and Comfort Questions and Answers