RN NCLEX-RN Basic Care & Comfort 4 — Questions and Answers
Question 1: A nurse is preparing to administer a cleansing enema. At what angle should the rectal tube be inserted in an adult?
- Directed downward toward the umbilicus
- Directed upward toward the umbilicus (Correct answer)
- Directed laterally toward the left hip
- Perpendicular to the body
Correct answer: Directed upward toward the umbilicus
The rectal tube is inserted at about a 30–40° angle directed toward the umbilicus to follow the natural curve of the rectum and sigmoid colon.
Question 2: A client using a walker is preparing to sit in a chair. What is the correct sequence of actions?
- Back up to the chair, feel for the seat, then lower into the chair while holding the walker
- Sit first, then position the walker in front
- Turn to face the chair, place the walker beside it, then sit
- Back up to the chair, place both hands on the armrests, then lower into the chair (Correct answer)
Correct answer: Back up to the chair, place both hands on the armrests, then lower into the chair
The client backs up, confirms contact with the chair, then transfers grip to the armrests for a stable, controlled seated transfer.
Question 3: A client has a prescription for sitz baths after hemorrhoid surgery. Which instruction is correct?
- Use water at 105–110°F for maximum therapeutic benefit
- Sit in the sitz bath for 20 minutes three to four times per day (Correct answer)
- Add iodine solution to the water to prevent infection
- Avoid the sitz bath if any drainage is present
Correct answer: Sit in the sitz bath for 20 minutes three to four times per day
Sitz baths at comfortable warm temperature (98–105°F) for 20 minutes, three to four times daily, promote comfort and healing after anorectal surgery.
Question 4: A nurse is caring for a client who reports pain rated 8/10 after repositioning. The nurse has a PRN analgesic order. What should the nurse do first?
- Administer the PRN analgesic immediately
- Reassess pain in 30 minutes after non-pharmacological measures
- Ask the client to rate their pain again in 15 minutes
- Perform a focused assessment to identify the cause and character of pain (Correct answer)
Correct answer: Perform a focused assessment to identify the cause and character of pain
A complete pain assessment (location, quality, onset, aggravating factors) before intervention ensures the correct treatment and identifies any new complications.
Question 5: Which action by a nursing student during perineal care of a female client requires correction?
- Cleaning from the urethral meatus toward the anus
- Using a clean section of cloth for each stroke
- Using warm water and mild soap
- Cleaning from the anus toward the urethral meatus (Correct answer)
Correct answer: Cleaning from the anus toward the urethral meatus
Cleaning from the anus toward the urethra introduces fecal bacteria to the urinary meatus, increasing urinary tract infection risk.
Question 6: A nurse is helping a client with chronic obstructive pulmonary disease (COPD) choose foods from the menu. Which option best reduces the work of breathing during meals?
- Three large meals with high carbohydrate content
- Five to six small, low-carbohydrate meals (Correct answer)
- Two large, high-protein meals per day
- Liquid nutritional supplements only
Correct answer: Five to six small, low-carbohydrate meals
Small frequent meals reduce diaphragm elevation from a full stomach, and low-carbohydrate foods produce less CO₂ during metabolism, reducing respiratory demand in COPD.
Question 7: A client is ordered a low-residue diet. Which food selection indicates understanding of the diet?
- Bran cereal with whole milk
- Steamed white rice with baked chicken breast (Correct answer)
- Raw broccoli salad with vinaigrette
- Whole wheat bread with peanut butter
Correct answer: Steamed white rice with baked chicken breast
White rice and baked chicken are low in fiber and residue, appropriate for a low-residue diet that minimizes bowel stimulation.
RN NCLEX-RN Basic Care & Comfort 4
A nurse is preparing to administer a cleansing enema.
At what angle should the rectal tube be inserted in an adult?