.png){kind=logo}
Basic Care and Comfort NCLEX questions ScienceMedicineNursing Jessi_Austin7 Save
NCLEX EXAM PREVIEW
110 terms kandykat1012Preview Reduction of Risk Potential NCLEX R...19 terms mgiven2capital Preview Exam Cram NCLEX-PN PRACTICE Q...103 terms summer3266Preview NCLEX 42 terms Kat Of the following positions, which one facilitates maximum air exchange?
- Orthopneic
- Trendelenburg
- High Fowler's
- Lithotomy
- Orthopneic
- Educate the family about custody of care and stay in the room
- Allow the ceremony and step out of the room
- Inform the family that religious rites are not allowed
- Allow the ceremony but remain as a witness
- Allow the ceremony and step out of the room
This is sitting in a leaning position, which allows for the most lung expansion.After your patient dies, the patient's family gathers at the bedside and asks you to step out while their clergy performs a religious rite for the deceased. As the patient's nurse, what is your most appropriate course of action?
Most hospitals do not have a policy that prohibits religious rites at the time of death. Remaining in the room shows disrespect and lack of trust a time of grieving.
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 (ADL)?
- TENS unit
- High-seat commode
- Recliner
- Abduction pillow
- High-seat commode
- I should walk around on my cast as soon as I get home.
- I will prop my cast on two pillows when I lie down.
- I'll put an ice pack over the cast to relieve itching.
- I should call my doctor if my toes turn blue or become numb.
- I should walk around on my cast as soon as I get home.
- a restricted-sodium diet
- a client with adequate caloric intake
- a diet high in grains
- a high-protein diet
- a restricted-sodium diet
- do a wet-to-dry dressing change
- cover with sterile gauze
- no dressing is necessary
- apply a hydrocolloid dressing
- no dressing is necessary
This keeps the hip higher than the knee.After a high school athlete sustains a fractured femur during a competition, a full leg plaster cast is applied. When the nurse provides discharge instructions to the athlete and their parents six hours later, which statement by the athlete indicates a need for further education?
Plaster casts are made up of a bandage and a hard covering, usually plaster of Paris. Client instructions include: 1) Keep the limb raised on a soft surface for as long as possible in the first few days, this will help decrease swelling. 2) Keep the cast dry; if the plaster gets wet, it weakens and is unable to support the bone. 3) Do not put anything into the cast to relieve itching. A hair dryer on cool or an ice pack over the itchy area can help. 4) Immediately report any pain, tingling, or numbness.When instructing a patient with Addison's disease about nutrition, the healthcare provider should NOT recommend which of the following dietary modifications?
A patient with Addison's disease (adrenal insufficiency) requires normal dietary sodium to maintain electrolyte balance and prevent excess fluid loss.A nurse is caring for a client whose heel has a pressure ulcer covered with intact hard, dry, black tissue. Which is the appropriate dressing for this client?
Current standard of care guidelines recommend that stable, intact (dry, adherent, intact without erythema) eschar on the heels should not be removed. Eschar works as a natural barrier or biological dressing by protecting the wound bed from bacteria. Unless it is wet, draining, or loose, it should remain in place.
When a patient's nasogastric (NG) tube stops draining, what is the nurse's first action?
- clamp for 1 hour
- check tube placement
- instill 50 mL of water
- retract 2 inches
- check tube placement
- The parents 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.
- The parents should open her eyes with a thumb and forefinger.
- The parents should put the drops into the inner canthus.
- Hold on to your doll, this is going to hurt.
- Just look at the TV while I do this.
- Tell me if this feels more like a pinch or a bug bite.
- 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.
- scrub the tubing toward the urinary meatus
- wipe the catheter away from the urinary meatus
- apply powder after giving perineal care
- vigorously wash the periurethral area
- wipe the catheter away from the urinary meatus
ALWAYS verify tube placement before taking other measures. NEVER put anything in an NG tube unless you know that its tip is in the stomach.Clamping has no effect on NG tube placement. Retracting without knowing where the tip is could be unsafe.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?
Infants instinctively resist anything regarding their eyes by tightly closing them. The best way to instill eye drops is to gently restrain the baby's head while the baby is in a supine position, and put the drops in the inner canthus of the eyes.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?
Children should be prepared for procedures. Educate them, but don't suggest that there will be pain. Allow them to decide if there is discomfort.When cleaning the perineal area around the site of an indwelling catheter, the nurse should
The catheter should be wiped away from the meatus, to decrease the risk of introducing pathogens into the urinary tract. The perineum should be washed gently with soap and water.
A patient diagnosed with Crohn's disease has a new colostomy. When assessing the patient's stoma, which of these would alert the healthcare provider that the stoma has retracted?
- narrowed and flattened
- dry and reddish purple
- concave and bowl shaped
- pinkish red and moist
- concave and bowl shaped
- warm saline rinses four times each day
- vigorous oral care with a commercial mouthwash
- plenty of ice chips between meals
- hot soup for lunch and dinner
- warm saline rinses four times each day
- compress the bulb and close the valve
- fill the bulb with sterile saline solution
- place the bulb lower than the client's body
- open the valve and fill the bulb with air
- compress the bulb and close the valve
- advise the family to increase the client's fluid and fiber intake
- teach family members to perform the disimpaction process
- give an analgesic or sedative to make the client comfortable
- recall that cardiac dysrhythmias are a possibility
- recall that cardiac dysrhythmias are a possibility
A healthy stoma will protrude about 2.5 cm with an open lumen at the top. The stoma should appear pinkish red and moist. A dry, dusky, or reddish-purple stoma indicates ischemia. A narrowed, flattened, or constricted stoma indicates stenosis. A concave and bowl-shaped stoma has retracted. A retracted stoma can be difficult to care for.A patient receiving chemotherapy is experiencing stomatitis. Which of the following should the healthcare provider offer the patient?
Stomatitis is irritation of the lips, mouth, tongue, and oropharynx, which occurs when chemotherapy kills healthy cells that are rapidly dividing. It can impair nutrition, speech, sleep, and quality of life. Warm saline rinses are non-irritating and help eliminate bacteria that can cause infection.After emptying a Jackson-Pratt drainage bulb, how does the nurse reestablish negative pressure in the system?
A Jackson-Pratt drain creates negative pressure when the bulb is compressed and the valve is closed. This causes fluid around the surgical site to flow into the drain.During assessment, the home health nurse learns that the client has a fecal impaction. Before proceeding to manually remove the stool, what is the nurse's PRIORITY?
Cardiac dysrhythmias and reflex bradycardia can occur from vagal nerve stimulation.
.png)