NCLEX Basic Care & Comfort

NCLEX Basic Care & Comfort 5.0 (2 reviews) Students also studied Terms in this set (37) Science MedicineNursing Save Basic Care and Comfort NCLEX que...44 terms Jessi_Austin7Preview NCLEX basic care and comfort 116 terms lauren_cook524 Preview NCLEX Basic Care and Comfort 33 terms Kate383Preview PassPo 71 terms Ran The client with tuberculosis is to be discharged home with nursing follow-up. Which aspect of nursing care will have the highest priority?

• assessing the client's environment for sanitation
• coordinating various agency services
• teaching the client about the disease and its treatment
• offering the client emotional support

teaching the client about the disease and its treatment

Explanation:

Ensuring that the client is well educated about tuberculosis is the highest priority.Education of the client and family is essential to help the client understand the need for completing the prescribed drug therapy to cure the disease.Which of the following expected outcomes would be appropriate for the client who has ulcerative colitis? The

client:

a) Maintains a daily record of intake and output.

b) Uses a heating pad to decrease abdominal cramping.

c) Accepts that a colostomy is inevitable at some time in

his life.

d) Verbalizes the importance of small, frequent feedings.

Verbalizes the importance of small, frequent feedings.

Explanation:

Small, frequent feedings are better tolerated by clients with ulcerative colitis as they lessen the amount of fecal material present in the gastrointestinal tract and decrease stimulation.A 5-year-old child with burns on the trunk and arms has no appetite. The nurse and parent develop a plan of care to stimulate the child's appetite. Which suggestion made by the parent would indicate the need for additional teaching?

• deciding that the parent will feed the child
• serving smaller and more frequent meals
• offering the child finger foods that the child likes
• withholding dessert and treats unless meals are eaten

withholding dessert and treats unless meals are eaten

Explanation:

Withholding certain foods until the child complies is punitive and rarely successful.

A nurse is caring for a severely depressed client who is barely functioning. The priority nursing goal for this client

would be to:

• assess for level of depression and continue

antidepressant medication.

• assess for and maintain adequate nutrition and

hydration.

• assess for the client's hygiene needs and ensure that

these needs are met.

• involve the client's family in his care as much as

possible.assess for and maintain adequate nutrition and hydration.

Explanation:

Food and fluid intake may be compromised in a client who is severely depressed.The nurse must ensure that the client is adequately hydrated and is receiving proper nutrition An adolescent is diagnosed with iron deficiency anemia.After emphasizing the importance of consuming dietary iron, the nurse asks him to select iron-rich breakfast items from a sample menu. Which selection demonstrates knowledge of dietary iron sources?

a) Ham and eggs

b) Bagel and cream cheese

c) Grapefruit and white toast

d) Pancakes and a banana

Ham and eggs

Explanation:

Good sources of dietary iron include red meat, egg yolks, whole wheat breads, seafood, nuts, legumes, iron-fortified cereals, and green, leafy vegetables.Which intervention is essential when performing dressing changes on a client with a diabetic foot ulcer?

a) Using sterile technique during the dressing change

b) Cleaning the wound with a povidone-iodine solution

c) Debriding the wound three times per day

d) Applying a heating pad

Remove elastic stockings once per day and observe lower extremities.

Explanation:

Elastic stockings are used to promote venous return and prevent deep vein thrombosis. A client with peripheral vascular disease and diabetes is at risk for skin breakdown, and the nurse must therefore remove the stockings once per day to observe the condition of the skin The nurse is teaching the mother of a newly diagnosed diabetic child about the principles of the diabetic diet.Which of the following statements by the mother indicates effective teaching?

• "Snacks are used to keep blood glucose at acceptable

levels during times when the insulin level peaks."

• "By spreading the calories throughout the day in small,

frequent meals, the risk of hyperglycemia is eliminated."

• "Snacks are used to offset the desire for sweets and to

keep the meals smaller so my child can eat better."

• "Most children find it difficult to eat all the calories

required by their diets in three main meals." "Snacks are used to keep blood glucose at acceptable levels during times when the insulin level peaks."

Explanation:

Snacks are included in the diabetic diet to offset periods of peak insulin action.Because of the lack of pancreatic functioning, the child does not receive differing amounts of insulin in response to the glucose level in the bloodstream. The child with diabetes mellitus is given insulin at specific times; dietary intake must be matched to the insulin peaks and troughs.A child, age 2, with a history of recurrent ear infections is brought to the clinic with a fever and irritability. To elicit the most pertinent information about the child's ear

problems, the nurse should ask the parent:

• "Does your child tug at either ear?"
• "Does anyone in your family have hearing problems?"
• "Does your child have any hearing problems?"
• "Does your child's ear hurt?"

"Does your child tug at either ear?"

Explanation:

Although all of the options are appropriate questions to ask when assessing a young child's ear problems, questions about the child's behavior, such as "Does your child tug at either ear?" are most useful because a young child usually can't describe symptoms accurately.

Which of the following interventions would likely be most effective for the client to use at home when managing the discomfort of rhinoplasty 2 days after surgery?

a) Lying in a prone position.

b) Applying ice compresses.

c) Blowing the nose gently.

d) Applying warm, moist compresses.

Applying ice compresses.

Explanation:

The most effective way to decrease discomfort is to decrease local edema. Cold application, such as an ice compress or ice bag, is effective.A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client?

a) By supplying a magic slate or similar device

b) By placing the call button under the client's pillow

c) By suctioning the client frequently

d) By providing a tracheostomy plug to use for verbal

communication By supplying a magic slate or similar device Correct

Explanation:

The nurse should use a nonverbal communication method, such as a magic slate, note pad and pencil, and picture boards (if the client can't write or speak English).A 7-year-old client is admitted to the hospital for a tonsillectomy. After the surgery, the physician orders a clear liquid diet. The nurse is correct in giving the child which items? Select all that apply.

a) Ice cream

b) Lime gelatin

c) Orange juice

d) Cream of chicken soup

e) Chicken broth

f) Apple juic

• Apple juice • Chicken broth • Lime gelatin Correct

Explanation:

Clear liquids include clear broth, gelatin, clear juices, water, and ice chips The nurse is teaching the mother of a newly diagnosed diabetic child about the principles of the diabetic diet.Which of the following statements by the mother indicates effective teaching?

• "Snacks are used to offset the desire for sweets and to

keep the meals smaller so my child can eat better."

• "Snacks are used to keep blood glucose at acceptable

levels during times when the insulin level peaks."

• "Most children find it difficult to eat all the calories

required by their diets in three main meals."

• "By spreading the calories throughout the day in small,

frequent meals, the risk of hyperglycemia is eliminated." "Snacks are used to keep blood glucose at acceptable levels during times when the insulin level peaks." Correct

Explanation:

Snacks are included in the diabetic diet to offset periods of peak insulin action.Because of the lack of pancreatic functioning, the child does not receive differing amounts of insulin in response to the glucose level in the bloodstream. The child with diabetes mellitus is given insulin at specific times; dietary intake must be matched to the insulin peaks and troughs.Which diet would be most appropriate for the client with ulcerative colitis?

• high-calorie, low-protein
• low-fat, high-fiber
• high-protein, low-residue
• low-sodium, high-carbohydrate

high-protein, low-residue Correct

Explanation:

Clients with ulcerative colitis should follow a well-balanced high-protein, high- calorie, low-residue diet, avoiding such high-residue foods as whole-wheat grains, nuts, and raw fruits and vegetables. Clients with ulcerative colitis need more protein for tissue healing and should avoid excess roughage.

Following a precipitous birth, examination of the client's vagina reveals a fourth-degree laceration. Which intervention is appropriate when caring for this client?

a) Applying heat to limit edema during the first 12 to 24

hours

b) Instructing the client about the importance of perineal

(Kegel) exercises

c) Instructing the client to use two or more perineal pads

to cushion the area

d) Instructing the client to avoid using sitz baths if

ordered Instructing the client about the importance of perineal (Kegel) exercises

Explanation:

Kegel exercises, cold (not heat) applications, and sitz baths are all appropriate interventions for a client with a fourth-degree laceration.The nurse is caring for a 7-year-old child who has just returned from the postoperative unit after surgery. The child is playing in bed with toys. The child's parents are smiling and state, "Isn't it great that our child does not have any pain?" What is the best response by the nurse?

• "The child's activity level is the best indicator of pain."
• "Some children distract themselves with play while in

pain."

• "A child who resumes usual play is not experiencing

pain."

• "Children don't experience as much pain after surgery

as adults." "Some children distract themselves with play while in pain." Correct

Explanation:

Some children distract themselves with play or music while in pain and may sleep as a result of exhaustion.The nurse is caring for a full-term, nonmedicated, primiparous client who is in the transition stage of labor.The client is writhing in pain and saying, "Help me, help me!" Her last vaginal exam 1 hour ago showed that she was 8 cm dilated, +1 station, and in what appeared to be a comfortable position. What does the nurse anticipate as the highest priority intervention in caring for this client?

a) Perform a vaginal examination to determine if the

client is fully dilated.

b) Ask the client for suggestions to make her more

comfortable.

c) Help the client through contractions until a narcotic

can be given.

d) Palpate the bladder to see if it has become distended.

Perform a vaginal examination to determine if the client is fully dilated.Correct

Explanation:

Transition is the most difficult period of the labor process, and often when clients are tired, pain becomes more intensified. Clients during this stage verbalize anger and are outspoken and difficult to comfort. The most logical next step would be to determine if the client has completed transition and is ready to begin pushing.Performing a vaginal exam would provide this answer.When examining a client who has abdominal pain, a nurse

should assess:

• the symptomatic quadrant first.
• the symptomatic quadrant either second or third.
• any quadrant first.
• the symptomatic quadrant last.

the symptomatic quadrant last.Correct

Explanation:

The nurse should systematically assess all areas of the abdomen, if time and the client's condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This tightening would interfere with further assessment.