RN NCLEX-RN Basic Care & Comfort 5 — Questions and Answers
Question 1: A nurse is applying antiembolism stockings (TEDs) to a client. Which action is correct?
- Apply stockings while the client is standing at the bedside
- Apply stockings after the client has been up ambulating for 30 minutes
- Apply stockings in the morning before the client gets out of bed (Correct answer)
- Apply stockings only to the leg without an IV line
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.
Question 2: A nurse is caring for a client with dysphagia. Which dietary modification is the priority safety intervention?
- Serve all foods at room temperature
- Thicken liquids to the consistency prescribed by the speech therapist (Correct answer)
- Offer three large meals to ensure adequate nutrition
- Allow the client to self-feed without supervision
Correct 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.
Question 3: A nurse is caring for a client in skeletal traction. Which assessment finding requires the nurse to contact the provider?
- Pin sites that are slightly pink with small amounts of serous drainage
- Client reports mild muscle soreness at the traction site
- Pin sites with purulent drainage and surrounding warmth (Correct answer)
- Traction weights hanging freely off the floor
Correct 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.
Question 4: 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?
- Continue the exercise as long as the client does not verbally report pain
- Stop the exercise, assess the client's pain level, and document the finding (Correct answer)
- Apply more force to complete the full range of motion
- Administer the scheduled analgesic and resume exercises immediately
Correct 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.
Question 5: A nurse is caring for a client who has been placed in restraints. Which assessment must be completed and documented every 2 hours?
- Blood pressure and oxygen saturation
- Skin integrity, circulation, and the client's need for the restraint (Correct answer)
- Level of consciousness and pupillary response
- Urine output and fluid intake
Correct 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.
Question 6: 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?
- Notify the surgeon and prepare the client for emergency surgery
- Cover the wound with dry sterile gauze
- Cover the wound with sterile gauze moistened with normal saline (Correct answer)
- Apply an abdominal binder firmly over the wound
Correct 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.
Question 7: 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?
- Encourage the client to perform isometric and active range-of-motion exercises (Correct answer)
- Restrict fluid intake to reduce the risk of urinary tract infection
- Keep the head of the bed flat at all times
- Limit visitors to reduce the client's activity
Correct 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.
RN NCLEX-RN Basic Care & Comfort 5
A nurse is applying antiembolism stockings (TEDs) to a client.
Which action is correct?