NCLEX: Basic Care & Comfort

NCLEX: Basic Care & Comfort

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NCLEX EXAM PREVIEW

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NCLEX-RN PRACTICE QUESTIONS

77 terms Dr_WhomPreview Roles o 62 terms Kat A 10-year-old boy is admitted to the pediatric unit with a diagnosis of viral meningitis. He is experiencing a severe headache, vomiting, photophobia, drowsiness, and a stiff neck. The nurse can make him more comfortable by

• Providing a large, soft pillow
• Closing the shades and dimming the lights
• Encouraging him to drink fluids
• Teaching him deep breathing
• Closing the shades and dimming the lights

A patient diagnosed with Crohn's disease has a new colostomy. When assessing the patient's stoma, which of these will alert the healthcare provider that the stoma has retracted?

• Pinkish-red and moist
• Dry and reddish-purple
• Narrowed and flattened
• Concave and bowl-shaped
• Concave and bowl-shaped

The home health nurse notices that a client with a diagnosis of multiple sclerosis is having a recent difficulty chewing and swallowing. The appropriate diet for this client is

• Mechanical soft
• Pureed
• Full liquid
• Clear liquid
• Mechanical soft

A patient with a total hip replacement requires certain equipment for recovery. Which of the following will assist the patient with activities of daily living?

• High-seat commode
• TENS unit
• Abduction pillow
• Recliner
• High-seat commode

Which lab value indicates hypokalemia?

• 5.6 mEq/L
• 3.6 mEq/L
• 3.2 mEq/L
• 4.2 mEq/L
• 3.2 mEq/L

The nurse is teaching parents to instill eye drops for their 4-month-old daughter. The parents tell the nurse that she shuts her eyes tightly to avoid the drops. Which instruction by the nurse is most appropriate?

• They should instill the drops into the conjunctival sac.
• The parents should wait until their daughter is relaxed.
• The parents should put the drops into the inner

canthus.

• They should open her eyes with a thumb and

forefinger.

• The parents should put the drops into the inner canthus.

A nurse working at a community health fair is administering intramuscular injections of flu vaccinations.Which injection technique will avoid leakage into subcutaneous tissue?

• Injection at a 45-degree angle
• Injection by Z-track method
• Massaging the injection site
• Aspiration prior to injection
• Injection by Z-track method

Which of the following is the proper procedure for cleaning and storing of dentures as part of a client's HS oral care?

• Remove dentures, clean with cool water, place in

denture cup with cool water, leave within reach at client's bedside.

• Remove dentures, rinse them quickly with hot water,

place on paper towel next to the sink.

• Remove dentures, clean with hot water, place in empty

denture cup, leave within reach at client's bedside.

• Remove dentures, clean with cool water, wrap them in

a clean washcloth, leave next to the sink.

• Remove dentures, clean with cool water, place in denture cup with cool water,

leave within reach at client's bedside.

When taking the blood pressure of a client who is seated, which position must the client change so that the nurse can get an accurate measurement?

• uncross their legs
• lean head back
• put down phone
• sit up straight
• uncross their legs

A pediatric patient has been diagnosed with right lower lobe pneumonia. Upon auscultation of this lung field, the nurse would expect to hear which breath sound?

• wheezes
• rhonchi
• crackles
• stridor
• crackles

A female patient complains of abdominal discomfort.Watery stool has been leaking from her rectum. This could be a sign of

• fecal impaction
• diarrhea
• bowel incontinence
• constipation
• fecal impaction

The nurse prepares a 5-year-old girl for a pre-operative IV insertion. Which statement is most appropriate to reduce the child's anxiety?

• "Hold onto your doll. This is going to hurt."
• "It's going to hurt a little, but I know you're a brave girl."
• "Tell me if this feels more like a pinch or a bug bite."
• "Just look at the television while I do this."
• "Tell me if this feels more like a pinch or a bug bite."

The nurse is providing education for a client who has just been prescribed a transcutaneous electrical nerve stimulation (TENS) unit for relief of chronic back pain.Which of the following instructions for the client is correct?

• "Muscle twitching means the TENS is working."
• "Each TENS unit session lasts about 3 hours."
• "It will take several days to build up a tolerance."
• "Do not go to sleep with the TENS unit on."
• "Do not go to sleep with the TENS unit on."

The parent of a child with a short leg fiberglass cast phones the clinic because their child complains of a constant itching inside the cast. Which intervention is appropriate for the nurse to suggest?

• Use a blunt-ended object to scratch.
• Apply powder or a mild lotion.
• Trickle ice water into the cast.
• Tap on the cast at the itchy spot.
• Tap on the cast at the itchy spot.

When instructing a patient with Addison's disease about nutrition, which of the following diet modifications is NOT recommended?

• a diet with adequate caloric intake
• a diet high in grains
• a high protein diet
• a restricted sodium diet
• a restricted sodium diet

The patient receiving chemotherapy is experiencing stomatitis. The healthcare provider should offer the patient

• hot soup for lunch and dinner.
• warm saline rinses four times each day.
• plenty of ice ships between meals.
• vigorous oral care with a commercial mouthwash.
• warm saline rinses four times each day.

A patient with a diagnosis of lung cancer is receiving chemotherapy and reports nausea and loss of appetite resulting in decreased food intake. What should the healthcare provider recommend to promote adequate nutrition? Advise the patient to

• eat only when feeling hungry.
• eat small meals throughout the day.
• eat only favorite foods to increase appetite.
• eat large meals but less frequently throughout the day.
• eat small meals throughout the day.

Out of the following positions, which of the following facilitates maximum air exchange?

• Lithotomy
• High Fowler's
• Orthopneic
• Trendelenburg
• Orthopneic

When measuring an adult client's apical heart rate, where does the nurse place the stethoscope?

• fifth left intercostal space at midclavicular line
• second left intercostal space at midclavicular line
• fourth left intercostal space at midclavicular line
• third left intercostal space at midclavicular line
• fifth left intercostal space at midclavicular line

A client comes to the clinic complaining of severe gastrointestinal distress. Which abdominal assessment step does the nurse do first?

• auscultation
• percussion
• palpation
• inspection
• inspection