NCLEX Basic Care and Comfort

NCLEX Basic Care and Comfort Leave the first rating Students also studied Terms in this set (33) Science MedicineNursing Save Reduction of Risk 86 terms wagnej6420Preview NCLEX basic care and comfort 116 terms lauren_cook524 Preview NCLEX practice attempt 1 121 terms acoates1996Preview Review 125 term tay The primary healthcare provider (PHP) has prescribed a saline IM injection for a client who requests pain medication every 2-3 hours. What would be the nurse's best first action?

• Administer the injection.
• Take vital signs.
• Question prescription with primary healthcare

provider.

• Notify the nursing supervisor.
• Question prescription with primary healthcare provider.

(3. Correct: A placebo is any medication or procedure that produces an effect in clients resulting from its implicit or explicit intent and not from its physical or chemical properties. An example would be a sugar pill or injection of saline. Some professionals try to justify the use of placebos to elicit the desirable placebo effect or in a misguided attempt to determine if the client's pain is real. These reasons cannot be justified on either a clinical or ethical basis, except in an approved research study. It is deceptive and represents fraudulent and unethical treatment.

1. Incorrect: Giving a placebo is fraudulent and unethical treatment.

• Incorrect: Taking the vital signs does not take care of the problem of giving a

placebo.

4. Incorrect: First, the nurse should discuss the prescription with the primary

healthcare provider.)

Which suggestion should the nurse provide to a client reporting frequent episodes of constipation?

• Take a stool softener.
• Increase intake of fruit in the diet.
• Monitor elimination habits for the next week.
• Rest after each meal.
• Increase intake of fruit in the diet.

(2. Correct: Increased fiber intake may help to establish regular elimination habits.

1. Incorrect: Not the best initial suggestion. It's better to promote health

maintenance routines than to just go with a medication, which could be a temporary fix.

• Incorrect: The nurse should make a suggestion that will assist the client with

normal elimination. This option does not suggest a way to fix the problem.

• Incorrect: Increased activity is likely to result in more normal elimination.

Resting after meals would not increase elimination frequency.) The nurse is administering medication to an elderly client who has no visitors. The client takes the pills, and, as the client hands the medication cup back to the nurse, grabs onto the nurse's hand tightly. What is the most logical rationale for the client's action?

• Confusion and disorientation.
• Scared and lonely and grabs the nurse's hand for

comfort.

• Would like to talk with the nurse.
• Would like to reminisce with the nurse.
• Scared and lonely and grabs the nurse's hand for comfort.

(2. Correct: This elderly client with no visitors is most likely scared and lonely. The touch of the nurse's hand is comforting for the client.

1. Incorrect: There is no indication of confusion or disorientation.

• Incorrect: Grabbing the nurse's hand indicates more than just a desire to talk.

This is indicative of needing comfort and personal touch.

• Incorrect: There is no indication of a desire to reminisce from the information in

the question.) A nurse has educated a client on crutch walking. Which statement by the client would indicate to the nurse that the client needs further instruction?

• "I will not alter the height of my crutches."
• "My body weight should be supported at the hand

grips with my elbows flexed at 30 degrees."

• "When I rise from a chair, I should position my crutches

on my unaffected side."

• "I will not lean on my crutches while standing."
• "When I rise from a chair, I should position my crutches on my unaffected side."

(3. Correct: The client should position crutches on affected side when sitting or rising from a chair. This will give the client more stability with position changes.

• Incorrect: This is a correct statement by the client. Once the crutches have been

properly fitted, they should not be altered by the client.

2. Incorrect: This is a correct statement by the client. Body weight should be

supported at the hand grips, not under the arms. Elbows should be flexed 30 degrees.

4. Incorrect: Leaning on crutches under the arms can damage the nerves.)

The nurse reassesses the client's pain level after administering an oral analgesic. The client states that the pain is better but continues to report a backache. Which non-pharmacologic interventions may help the client's backache?Select all that apply.

• Educating the client regarding pain and pain control.
• Assisting the client into a side lying position.
• Providing a back massage.
• Providing heat therapy.
• Using distraction techniques.
• Assisting the client into a side lying position.
• Providing a back massage.
• Providing heat therapy.
• Using distraction techniques.

(2., 3., 4. & 5. Correct: Assisting the client to a side lying position, providing a back massage, providing heat therapy, and using distraction techniques are all proven interventions that can raise the client's pain threshold. In other words, raise the level at which a client first perceives a stimulus as pain. All of these provide comfort, are non-invasive, and show the client that the nurse cares.

• Incorrect: Education regarding pain control does not help the client's pain and

would not be appropriate while the client is experiencing pain.) The nurse is planning to discuss pain management with a client who experiences chronic pain. How should the nurse best begin this discussion?

• "Please tell me how I can best help you control your

pain."

• "It is my job to teach you how to deal with your pain."
• "I will be teaching you how to use guided imagery to

decrease your pain."

• "Your primary healthcare provider has prescribed pain

medication for your pain. I will teach you about this medication."

• "Please tell me how I can best help you control your pain."

(1. Correct: This statement sends a couple of messages that are an important part of treatment planning and evaluation of care. First, it places the ownership and responsibility for controlling pain on the client. Second, it acknowledges that the client may be the best judge of what is needed, respecting the cultural meaning of pain, and acceptable ways of expressing/controlling pain. Third, it establishes the nurse's role in helping the client be more comfortable and in control of their condition.

2. Incorrect: This statement does not include or even consider the client. This

statement reflects the role of the nurse. The focus should be on the client's needs.

• Incorrect: This statement begins with what the nurse is planning to accomplish.

This statement does not include or even consider the client.

• Incorrect: What does the client think might help relieve the pain? What other

options are there? The nurse begins the teaching session by what the primary healthcare provider has ordered. The nurse should assess the client's knowledge about pain management.) As part of the screening process to identify if a client is obese, the nurse calculates the client's body mass index

(BMI).

Weight - 180 pounds Height - 5' 5" Calculate the BMI to the whole number.

Ans:______

30

(Rationale:

BMI = kg/m²

(180 ÷ 2.2) ÷ ((65 × 2.54) ÷ 100)²

(180 ÷ 2.2) ÷ (165.1 ÷ 100)²

(180 ÷ 2.2) ÷ (1.651)² ≈ 30

Ans: 30)

A client of Jewish faith has requested a Kosher diet. Which food tray would the nurse provide to the client?

• Medium rare steak, potato salad, peas and coffee
• Ham sandwich, chips, fruit salad and juice
• Broiled white fish, baked potato, mixed salad and tea
• Baked chicken, vegetable medley, rice and milk
• Broiled white fish, baked potato, mixed salad and tea

(3. Correct: Fish is allowed if it has fins and scales. Shellfish is not kosher. Pasta, potatoes, salads and tea are allowed.

1. Incorrect: Although steak is allowed, all traces of blood must be gone.

2. Incorrect: No pork products are allowed, so no bacon, ham, or sausage.

• Incorrect: Milk is not allowed at the same time as meat. There should be at least

three hours separating the two.) The nurse is preparing to collect a capillary blood specimen for measuring blood glucose. Which action is most likely to result in an adequate stick for the client?

• Place the finger at heart level when making the stick.
• Warm the finger prior to the stick.
• Keep the injector loose against the skin.
• Place the finger above heart level when making the

stick.

• Warm the finger prior to the stick.

(2. Correct: Warming the finger will increase circulation to the site, thereby

increasing blood flow.

• Incorrect: The finger should be dependent to enhance blood flow to the site, so

it needs to be below the level of the heart to be effective.

• Incorrect: The injector should be placed firmly against the skin; otherwise the

client may get an insufficient stick and require another stick.

• Incorrect: The finger should be in a dependent position to increase blood flow

to the site so as to prevent the need for another stick.) The nurse is planning care for a client who has a fractured hip. Which nursing interventions should the nurse plan to use for impaired physical mobility?Select all that apply.

• Turn every two hours
• Place a pillow between legs when turning
• Sit in a chair three times per day
• Encourage fluid intake
• Encourage ankle and foot exercises
• Turn every two hours
• Place a pillow between legs when turning
• Encourage fluid intake
• Encourage ankle and foot exercises

(1., 2., 4. & 5. Correct: The client must be turned every two hours. You may not be able to turn the client totally on the side of the fracture, but you must relieve pressure points. Place pillow between legs to keep affected leg in abducted position. Encourage fluid intake and ankle and foot exercises to prevent deep vein thrombosis (DVT).

• Incorrect: The client has a fractured hip that has not been surgically fixed.

Sitting up in a chair could do more injury and cause more pain.)