NCLEX-RN Basic Care & Comfort Flashcards

A nurse is applying antiembolism stockings (TEDs) to a client. Which action is correct?

Answer: Apply stockings in the morning before the client gets out of bed

Antiembolism stockings should be applied before the client gets out of bed to prevent venous pooling that occurs with dependency, maximizing their effectiveness.

A nurse is caring for a client with dysphagia. Which dietary modification is the priority safety intervention?

Answer: Thicken liquids to the consistency prescribed by the speech therapist

Thickened liquids slow the flow of food/fluid to allow time for the impaired swallowing reflex to activate, directly reducing aspiration risk in dysphagia.

A nurse is caring for a client in skeletal traction. Which assessment finding requires the nurse to contact the provider?

Answer: Pin sites with purulent drainage and surrounding warmth

Purulent drainage and warmth at pin sites indicate infection, a serious complication of skeletal traction that requires prompt provider notification.

A nurse is performing range-of-motion exercises on a client's shoulder. The client grimaces when the arm is abducted. What should the nurse do?

Answer: Stop the exercise, assess the client's pain level, and document the finding

Non-verbal pain cues such as grimacing indicate the client is experiencing pain and the nurse must stop, assess, and document before proceeding.

A nurse is caring for a client who has been placed in restraints. Which assessment must be completed and documented every 2 hours?

Answer: Skin integrity, circulation, and the client's need for the restraint

Every 2-hour restraint checks must include circulatory status, skin integrity, and re-evaluation of whether the restraint remains necessary per The Joint Commission standards.

A client who had abdominal surgery reports a 'popping sensation' and the nurse observes the wound edges have separated with loops of bowel visible. What is the first action?

Answer: Cover the wound with sterile gauze moistened with normal saline

Wound evisceration requires covering exposed bowel with sterile saline-moistened gauze to keep tissue moist and prevent injury while the surgeon is notified.

A nurse is caring for a client prescribed complete bed rest. Which intervention is most important to include in the plan of care to prevent complications?

Answer: Encourage the client to perform isometric and active range-of-motion exercises

Isometric and range-of-motion exercises maintain muscle strength, joint mobility, and venous return, preventing the primary complications of immobility.