NCLEX-RN Basic Care & Comfort Flashcards

A patient with primary adrenal insufficiency (Addison's disease) is receiving education from the nurse regarding dietary and nutritional adjustments necessary to manage the client's condition. Which of the following statements made by the patient would suggest that the nurse's recommendations were successful?

Answer: I should increase sodium and fluids, but limit potassium.

Patients with Addison's disease have primary adrenal insufficiency, leading to decreased aldosterone production. This hormonal imbalance results in hyponatremia (low sodium), hyperkalemia (high potassium), and fluid volume deficit. Therefore, increasing sodium and fluids helps correct these deficits, while limiting potassium prevents further hyperkalemia, making the patient's statement correct.

Which positioning is ideal for the client before to a soap suds enema?

Answer: Sims

The Sims position, where the patient lies on their left side with the right knee and thigh drawn up, is the ideal positioning for a soap suds enema. This position allows gravity to assist the flow of the enema solution into the descending colon and rectum. It also helps to relax the anal sphincter, making the procedure more comfortable and effective for the client.

The nurse is giving advice to a patient who will soon undergo surgery to remove a descending colostomy. What kind of stools might the patient anticipate following surgery?

Answer: Semi-formed to formed

A descending colostomy is located in the descending colon, which is the most distal part of the large intestine where significant water absorption occurs. After the removal of a descending colostomy and restoration of bowel continuity, the patient can anticipate stools that are semi-formed to formed. This is because the stool has had ample time to solidify as it passes through the majority of the colon.

Which step is most appropriate when providing postmortem care for a patient who will donate an eye?

Answer: Cover the eyes with saline-soaked pads and place the patient in a low Fowler's position.

When providing postmortem care for a patient who will donate an eye, it is crucial to maintain the integrity and moisture of the corneas. Covering the eyes with saline-soaked pads helps prevent drying and damage to the delicate tissues. Placing the patient in a low Fowler's position can help reduce blood pooling in the head, which is generally recommended for postmortem care, without compromising the eyes.

A nasogastric (NG) tube is used by one of the nurse's patients to provide medications and for tube feedings. Which nursing intervention is suitable for this patient's care?

Answer: Check the area where the tape is applied qd.

When a patient has a nasogastric (NG) tube, it is essential to regularly assess the skin integrity around the tape application site daily (qd). This intervention helps prevent skin irritation, breakdown, or pressure injuries that can result from constant pressure and moisture under the tape. Proper skin care ensures patient comfort and prevents complications related to the NG tube.

A vegetarian client is being instructed by the nurse in the prenatal clinic on how to prevent iron deficiency anemia while pregnant. Which food selection made by the client suggests that more teaching is required?

Answer: Scrambled eggs and wheat toast

For a vegetarian client, scrambled eggs and wheat toast are not the best choices for preventing iron deficiency anemia. While eggs contain some iron, it is non-heme iron, which is less readily absorbed than heme iron from meat. Furthermore, this meal lacks a significant source of vitamin C, which is crucial for enhancing the absorption of non-heme iron from plant-based foods, unlike the other options that pair iron sources with vitamin C-rich foods.

What is the appropriate way to respond to a patient at the senior living facility who throws his tray to the ground and yells, "This food is terrible! I can't stand this another minute!"

Answer: Let's find something you might like better. Tell me what sounds good.

The most appropriate response is to address the patient's immediate need and feelings in a therapeutic and patient-centered manner. Offering to find something they might like better de-escalates the situation, validates their distress without condoning the behavior, and focuses on a practical solution. This approach maintains respect for the patient while ensuring their nutritional needs are met.

The nurse brings an Orthodox Jewish customer a dinner tray. A cheeseburger with lettuce and tomato, French fries, a fruit salad, and a vanilla milkshake are all included on the tray. Which of the nurse's actions is BEST?

Answer: Remove the tray and order a new meal

Orthodox Jewish dietary laws (Kosher) strictly prohibit the consumption of meat and dairy products together in the same meal. A cheeseburger (meat and dairy) and a vanilla milkshake (dairy) violate these laws. Therefore, the nurse must remove the entire tray and order a new meal that adheres to the client's religious dietary restrictions to ensure cultural and religious sensitivity.

Congestive heart failure (CHF) patients must follow rigorous intake and output (I&O) guidelines with daily weights. The client's intake was 2200 mL, and their output was 1200 mL throughout the 24-hour I&O, according to the nurse. What would the probable next daily weight be?

Answer: 2.2 lb gain

To determine the probable weight change, first calculate the net fluid balance: Intake (2200 mL) - Output (1200 mL) = 1000 mL positive fluid balance. Since 1 liter (1000 mL) of fluid is approximately equivalent to 2.2 pounds, a positive fluid balance of 1000 mL indicates a weight gain of 2.2 lbs. This fluid retention is a common concern for patients with Congestive Heart Failure.

Which of the following assessment results is in line with a volume deficit of extracellular fluid?

Answer: Oliguria

Extracellular fluid volume deficit, or hypovolemia, signifies a reduction in the body's circulating fluid volume. The kidneys respond to this decreased volume by conserving water, leading to reduced urine output, known as oliguria. Other common signs of fluid volume deficit include tachycardia, hypotension, and dry mucous membranes, not bradycardia or hypertension.

A patient requests the nurse's advice on a breakfast that can aid with constipation prevention during a normal check-up. Which of the following food options would be the best?

Answer: Oatmeal and a banana

Oatmeal and a banana are excellent choices for preventing constipation due to their high fiber content. Oatmeal provides both soluble and insoluble fiber, which adds bulk to stool and promotes regular bowel movements, while bananas also contribute dietary fiber. The other options are generally low in fiber or high in fat, which can exacerbate constipation.

A patient is in an awkward position in her bed when the nurse enters the room to inject insulin. What should the nurse start by doing?

Answer: Reposition the patient

Before administering any medication, especially an injection, patient safety and comfort are paramount. If the patient is in an awkward position, the nurse should first reposition them to ensure proper body alignment, comfort, and accessibility to the injection site. This step helps prevent injury to both the patient and the nurse during the procedure.

Right lower lobe (RLL) pneumonia has been identified in a pediatric child who has been admitted to the unit. What noise ought the nurse to listen for when auscultating the RLL?

Answer: Crackles

Pneumonia, particularly in the lower lobes, causes inflammation and fluid accumulation in the alveoli and small airways. When auscultating the lungs of a child with right lower lobe (RLL) pneumonia, the nurse would most likely hear crackles (also known as rales). These are short, popping sounds caused by air passing through fluid or mucus.

A young client with leukemia is having nausea and vomiting as a result of chemotherapy. Which of the following foods will be the BEST at now supplying enough nutrition?

Answer: Cold foods with no smell

Patients undergoing chemotherapy often experience nausea and vomiting, and strong food odors can exacerbate these symptoms. Cold foods tend to have less odor than warm foods, making them more palatable and easier to tolerate for patients with chemotherapy-induced nausea. Bland, cold, and odorless options are generally preferred to help maintain some nutritional intake during this challenging time.

The nurse is giving parents of a 3-year-old who was admitted to the hospital with severe croup guidelines for release. What non-pharmaceutical measures can parents take at home in the event of a subsequent croup attack?

Answer: Take the child into a steamy bathroom

For a child experiencing a croup attack, moist, cool air helps to reduce laryngeal swelling and ease breathing. Taking the child into a steamy bathroom (created by running hot water in the shower) or exposing them to cool night air can provide symptomatic relief. The humidity helps to loosen secretions and soothe the inflamed airways, making it easier for the child to breathe.

A expectant client makes her first visit to the prenatal clinic. This is the client's third pregnancy, the nurse observes. She gave birth to a healthy boy four years ago at 38 weeks, and a healthy girl two years ago at 35 weeks. The nurse will document the client's obstetrical history using the gravida/para method.

Answer: Gravida 3 - Para 2

Gravida refers to the total number of pregnancies, including the current one. This client has had two previous pregnancies and is currently pregnant, making her Gravida 3. Para refers to the number of pregnancies that reached viability (typically 20 weeks gestation) or resulted in live births. She has had two live births (one at 38 weeks, one at 35 weeks), so her Para is 2.