RN NCLEX-RN Basic Care & Comfort 3

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?

Accepted Answer

Lower the client gently to the floor using the nurse's body as a guide

Answer

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?

Accepted Answer

Oxygen saturation of 90% with new onset cough

Answer

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?

Accepted Answer

Expose only the body part being washed, then dry it before moving on

Answer

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:

Accepted Answer

'No, crossing your legs could dislocate your new hip.'

Answer

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?

Accepted Answer

Hydrocolloid dressing changed every 3–5 days

Answer

Hydrocolloid dressings provide a moist wound environment that promotes healing for Stage 2 pressure injuries and require less frequent changes.

RN - Registered Nurse Practice Test