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, Basic Care & Comfort (1–12)
1. A nurse is caring for an immobile client. Which action should the nurse take first to prevent
a pressure injury?
A. Apply a hydrocolloid dressing to the sacrum
B. Reposition the client every 2 hours
C. Document the Braden Scale score
D. Elevate the head of the bed to 45 degrees
Answer: B
Rationale: Repositioning relieves pressure, the primary cause of pressure injury. Assessment
and documentation are important but do not replace the intervention. Elevating the head of the
bed increases shear and friction.
2. A nurse is providing oral care to an unconscious client. Which action is appropriate?
A. Use a toothbrush and water with the client supine
B. Position the client side-lying, have suction available, and use sponge swabs
C. Insert an oral airway before cleaning
D. Use lemon glycerin swabs every 2 hours
Answer: B
Rationale: Side-lying positioning and suction reduce aspiration risk. Lemon glycerin swabs can
dry oral mucosa and are not recommended.
3. A nurse is assessing pain in a client with dementia who is nonverbal. Which approach is
best?
A. Ask the client to rate pain on a 0–10 scale
B. Observe facial expressions, guarding, and changes in vital signs
C. Assume the client has no pain if they do not report it
D. Wait until the client can verbalize pain
Answer: B
Rationale: Nonverbal clients may show pain through grimacing, guarding, agitation, and vital
sign changes. Behavioral pain scales are appropriate.
4. A nurse is teaching a client about preventing constipation. Which instructions should the
nurse include? Select all that apply.
A. Increase dietary fiber
B. Increase fluid intake
C. Encourage regular mobility
, Basic Care & Comfort (1–12)
1. A nurse is caring for an immobile client. Which action should the nurse take first to prevent
a pressure injury?
A. Apply a hydrocolloid dressing to the sacrum
B. Reposition the client every 2 hours
C. Document the Braden Scale score
D. Elevate the head of the bed to 45 degrees
Answer: B
Rationale: Repositioning relieves pressure, the primary cause of pressure injury. Assessment
and documentation are important but do not replace the intervention. Elevating the head of the
bed increases shear and friction.
2. A nurse is providing oral care to an unconscious client. Which action is appropriate?
A. Use a toothbrush and water with the client supine
B. Position the client side-lying, have suction available, and use sponge swabs
C. Insert an oral airway before cleaning
D. Use lemon glycerin swabs every 2 hours
Answer: B
Rationale: Side-lying positioning and suction reduce aspiration risk. Lemon glycerin swabs can
dry oral mucosa and are not recommended.
3. A nurse is assessing pain in a client with dementia who is nonverbal. Which approach is
best?
A. Ask the client to rate pain on a 0–10 scale
B. Observe facial expressions, guarding, and changes in vital signs
C. Assume the client has no pain if they do not report it
D. Wait until the client can verbalize pain
Answer: B
Rationale: Nonverbal clients may show pain through grimacing, guarding, agitation, and vital
sign changes. Behavioral pain scales are appropriate.
4. A nurse is teaching a client about preventing constipation. Which instructions should the
nurse include? Select all that apply.
A. Increase dietary fiber
B. Increase fluid intake
C. Encourage regular mobility
