RN NCLEX-RN Basic Care & Comfort 3 — Questions and Answers
Question 1: A nurse is assisting a client with ambulation when the client says, 'I feel dizzy and my legs are giving out.' What should the nurse do first?
- Call for help loudly before doing anything else
- Lower the client gently to the floor using the nurse's body as a guide (Correct answer)
- Hold the client upright until help arrives
- Return the client to the room immediately
Correct answer: Lower the client gently to the floor using the nurse's body as a guide
Guiding the client to the floor controls the descent and prevents injury when a fall cannot be stopped, which is the safest immediate action.
Question 2: Which finding in a client receiving enteral tube feeding requires the most immediate nursing action?
- Gastric residual of 150 mL
- Tube feeding rate of 60 mL/hr
- Oxygen saturation of 90% with new onset cough (Correct answer)
- Blood glucose of 180 mg/dL
Correct answer: Oxygen saturation of 90% with new onset cough
New-onset cough with decreased oxygen saturation during tube feeding suggests aspiration, an immediate life-threatening complication.
Question 3: A nurse is performing a bed bath for an elderly client. Which action best promotes comfort and prevents chilling?
- Complete the entire bath before drying any area
- Expose only the body part being washed, then dry it before moving on (Correct answer)
- Keep the room temperature at 65°F to conserve water heat
- Use cold water to stimulate circulation
Correct answer: Expose only the body part being washed, then dry it before moving on
Exposing and drying one area at a time minimizes heat loss, prevents chilling, and preserves the client's dignity.
Question 4: A client with a hip replacement asks if they can cross their legs when sitting. The nurse's best response is:
- 'Yes, crossing at the ankles is acceptable.'
- 'No, crossing your legs could dislocate your new hip.' (Correct answer)
- 'Yes, crossing is fine as long as you feel comfortable.'
- 'No, but you may cross your legs after 6 weeks.'
Correct answer: 'No, crossing your legs could dislocate your new hip.'
Hip flexion beyond 90° and adduction, such as crossing legs, risk prosthesis dislocation after total hip replacement.
Question 5: A nurse is caring for a client with a Stage 2 pressure injury on the coccyx. Which dressing is most appropriate?
- Dry sterile gauze changed every 8 hours
- Hydrocolloid dressing changed every 3–5 days (Correct answer)
- Wet-to-dry gauze dressing
- Transparent film dressing with daily changes
Correct answer: Hydrocolloid dressing changed every 3–5 days
Hydrocolloid dressings provide a moist wound environment that promotes healing for Stage 2 pressure injuries and require less frequent changes.
Question 6: Which position is contraindicated for a client who had a transurethral resection of the prostate (TURP)?
- Semi-Fowler's at 45 degrees
- Supine with legs extended
- Lithotomy position (Correct answer)
- Sims' position
Correct answer: Lithotomy position
The lithotomy position increases pressure in the operative area and is contraindicated postoperatively after TURP to avoid bleeding and discomfort.
Question 7: A nurse is assisting a client with a bedpan. Which action best maintains the client's dignity and comfort?
- Leave the call light within reach and close the curtain while the client uses the bedpan (Correct answer)
- Stay at the bedside to monitor for complications
- Raise all four side rails for safety
- Perform perineal care before placing the bedpan
Correct answer: Leave the call light within reach and close the curtain while the client uses the bedpan
Providing privacy with a closed curtain and ensuring access to the call light respect dignity while maintaining safety.
RN NCLEX-RN Basic Care & Comfort 3
A nurse is assisting a client with ambulation when the client says, 'I feel dizzy and my legs are giving out.' What should the nurse do first?