RN NCLEX-RN Basic Care & Comfort 2 — Questions and Answers
Question 1: A nurse is caring for a client who is immobile and at risk for pressure injuries. Which intervention has the highest priority?
- Apply a moisture barrier cream to intact skin
- Reposition the client every 2 hours (Correct answer)
- Place a donut-shaped foam ring under the coccyx
- Massage reddened bony prominences vigorously
Correct answer: Reposition the client every 2 hours
Repositioning every 2 hours is the primary intervention to relieve sustained pressure on bony prominences and prevent tissue ischemia.
Question 2: A postoperative client refuses to use the incentive spirometer. Which response by the nurse is most therapeutic?
- Document the refusal and notify the provider
- Explain that using it prevents serious lung complications such as pneumonia (Correct answer)
- Tell the client it is required before discharge
- Perform chest physiotherapy instead
Correct answer: Explain that using it prevents serious lung complications such as pneumonia
Educating the client about the rationale (preventing atelectasis and pneumonia) supports informed decision-making and may improve adherence.
Question 3: When providing oral hygiene to an unconscious client, what is the most important safety measure?
- Use a soft-bristle toothbrush
- Position the client in a semi-Fowler's position
- Place the client in a lateral position with head turned to the side (Correct answer)
- Perform mouth care every 4 hours
Correct answer: Place the client in a lateral position with head turned to the side
A lateral position with the head turned to the side uses gravity to prevent aspiration of fluids in an unconscious client.
Question 4: A nurse is preparing to insert a urinary catheter in a female client. After opening the sterile field, which action would require the nurse to start over?
- Holding forceps with the dominant hand
- Pouring antiseptic solution into the sterile tray
- Reaching across the sterile field to arrange supplies (Correct answer)
- Applying sterile gloves using the glove-to-glove technique
Correct answer: Reaching across the sterile field to arrange supplies
Reaching across a sterile field contaminates it because the unsterile arm passes over the field; the nurse must start over with a new kit.
Question 5: A client with a nasogastric tube reports nausea. Before administering an antiemetic, the nurse should first:
- Check the placement of the nasogastric tube (Correct answer)
- Administer the antiemetic via IV instead
- Elevate the head of the bed to 90 degrees
- Remove the nasogastric tube temporarily
Correct answer: Check the placement of the nasogastric tube
Verifying NG tube placement rules out tube displacement into the esophagus as a cause of nausea before any intervention.
Question 6: A nurse is caring for a client who uses a cane. Which instruction is correct for descending stairs with a cane?
- Lead with the stronger leg, then bring the cane and weaker leg down
- Lead with the cane, then the weaker leg, then the stronger leg (Correct answer)
- Lead with the stronger leg only, keeping the cane stationary
- Lead with the weaker leg, then the cane, then the stronger leg
Correct answer: Lead with the cane, then the weaker leg, then the stronger leg
When descending, the cane and weaker leg go first so the stronger leg bears weight while the client lowers the affected side safely.
Question 7: A nurse observes that a client's surgical wound dressing is saturated with bright red blood 1 hour postoperatively. What is the priority action?
- Reinforce the dressing and document the finding
- Remove the dressing and inspect the wound
- Apply direct pressure and notify the surgeon immediately (Correct answer)
- Obtain a wound culture and change the dressing
Correct answer: Apply direct pressure and notify the surgeon immediately
Bright red saturation 1 hour post-op indicates active arterial bleeding; applying pressure and alerting the surgeon addresses the life-threatening emergency.
RN NCLEX-RN Basic Care & Comfort 2
A nurse is caring for a client who is immobile and at risk for pressure injuries.
Which intervention has the highest priority?