NCLEX RN Basic Care and Comfort
Exam 3 100 Questions And Correct
Answers (Verified Answers) and
Rationales 2026 Q&A Instant
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1. A nurse is caring for a client who has limited mobility. Which intervention is
most effective for preventing pressure injuries?
A. Massage reddened areas every shift
B. Reposition the client at least every 2 hours
C. Keep the head of the bed elevated at 45 degrees
D. Apply powder to areas of skin irritation
Answer: B. Reposition the client at least every 2 hours
Rationale: Regular repositioning relieves prolonged pressure over bony
prominences and helps prevent tissue ischemia and pressure injury formation.
2. Which position is best for a client experiencing shortness of breath?
A. Supine
B. Prone
C. High-Fowler's
D. Trendelenburg
Answer: C. High-Fowler's
Rationale: High-Fowler's positioning promotes maximum lung expansion and
decreases pressure from abdominal organs against the diaphragm.
,3. A client reports difficulty sleeping in the hospital. Which nursing
intervention is appropriate?
A. Offer caffeinated beverages at bedtime
B. Cluster nursing activities when possible
C. Keep the television on for distraction
D. Wake the client every hour for assessment
Answer: B. Cluster nursing activities when possible
Rationale: Clustering care minimizes nighttime interruptions and promotes
uninterrupted sleep.
4. A nurse is assisting a client with oral hygiene. Which action is appropriate
for an unconscious client?
A. Place the client flat on the back
B. Use a large amount of mouthwash
C. Position the client laterally
D. Insert a toothbrush deep into the mouth
Answer: C. Position the client laterally
Rationale: Lateral positioning facilitates drainage of oral secretions and
reduces the risk of aspiration.
5. Which intervention is appropriate when assisting a client with a bed bath?
A. Wash from the dirtiest area to the cleanest area
B. Use the same washcloth for all body areas
C. Expose only the area being washed
D. Use very hot water
Answer: C. Expose only the area being washed
Rationale: Limiting exposure maintains privacy, warmth, and dignity while
providing hygiene care.
,6. A client has dysphagia following a stroke. Which intervention is appropriate
during meals?
A. Encourage the client to drink through a straw
B. Place food on the affected side of the mouth
C. Position the client upright
D. Encourage talking while chewing
Answer: C. Position the client upright
Rationale: Upright positioning reduces the risk of aspiration and promotes
safer swallowing.
7. Which finding indicates that a client may be experiencing urinary
retention?
A. Frequent large-volume urination
B. Bladder distention
C. Clear urine
D. Urinary frequency without discomfort
Answer: B. Bladder distention
Rationale: Urinary retention commonly causes bladder distention, discomfort,
urgency, and small amounts of urine output.
8. A nurse is teaching a client about preventing constipation. Which
instruction is appropriate?
A. Limit fluid intake
B. Increase dietary fiber
C. Avoid physical activity
D. Use stimulant laxatives daily
Answer: B. Increase dietary fiber
Rationale: Fiber increases stool bulk and promotes regular bowel movements
when adequate fluid intake is maintained.
, 9. Which client should the nurse assess first?
A. A client requesting assistance with bathing
B. A client reporting mild constipation
C. A client with new difficulty breathing
D. A client requesting a change of linens
Answer: C. A client with new difficulty breathing
Rationale: New-onset respiratory difficulty may indicate an acute, potentially
life-threatening problem and requires immediate assessment.
10. Which intervention is appropriate for a client at risk for falls?
A. Keep the bed in the highest position
B. Keep frequently used items within reach
C. Encourage the client to walk without assistance
D. Keep the room dark at night
Answer: B. Keep frequently used items within reach
Rationale: Keeping needed items within reach reduces unnecessary attempts
to get out of bed and decreases fall risk.
11. A client is using a cane. Which instruction should the nurse provide?
A. Hold the cane on the stronger side
B. Hold the cane on the weaker side
C. Move the unaffected leg first every time
D. Keep the cane several feet ahead of the body
Answer: A. Hold the cane on the stronger side
Rationale: Holding the cane on the stronger side provides better support and
allows the stronger extremity to assist the weaker side.
12. Which action demonstrates proper use of a walker?
Exam 3 100 Questions And Correct
Answers (Verified Answers) and
Rationales 2026 Q&A Instant
Download Pdf
1. A nurse is caring for a client who has limited mobility. Which intervention is
most effective for preventing pressure injuries?
A. Massage reddened areas every shift
B. Reposition the client at least every 2 hours
C. Keep the head of the bed elevated at 45 degrees
D. Apply powder to areas of skin irritation
Answer: B. Reposition the client at least every 2 hours
Rationale: Regular repositioning relieves prolonged pressure over bony
prominences and helps prevent tissue ischemia and pressure injury formation.
2. Which position is best for a client experiencing shortness of breath?
A. Supine
B. Prone
C. High-Fowler's
D. Trendelenburg
Answer: C. High-Fowler's
Rationale: High-Fowler's positioning promotes maximum lung expansion and
decreases pressure from abdominal organs against the diaphragm.
,3. A client reports difficulty sleeping in the hospital. Which nursing
intervention is appropriate?
A. Offer caffeinated beverages at bedtime
B. Cluster nursing activities when possible
C. Keep the television on for distraction
D. Wake the client every hour for assessment
Answer: B. Cluster nursing activities when possible
Rationale: Clustering care minimizes nighttime interruptions and promotes
uninterrupted sleep.
4. A nurse is assisting a client with oral hygiene. Which action is appropriate
for an unconscious client?
A. Place the client flat on the back
B. Use a large amount of mouthwash
C. Position the client laterally
D. Insert a toothbrush deep into the mouth
Answer: C. Position the client laterally
Rationale: Lateral positioning facilitates drainage of oral secretions and
reduces the risk of aspiration.
5. Which intervention is appropriate when assisting a client with a bed bath?
A. Wash from the dirtiest area to the cleanest area
B. Use the same washcloth for all body areas
C. Expose only the area being washed
D. Use very hot water
Answer: C. Expose only the area being washed
Rationale: Limiting exposure maintains privacy, warmth, and dignity while
providing hygiene care.
,6. A client has dysphagia following a stroke. Which intervention is appropriate
during meals?
A. Encourage the client to drink through a straw
B. Place food on the affected side of the mouth
C. Position the client upright
D. Encourage talking while chewing
Answer: C. Position the client upright
Rationale: Upright positioning reduces the risk of aspiration and promotes
safer swallowing.
7. Which finding indicates that a client may be experiencing urinary
retention?
A. Frequent large-volume urination
B. Bladder distention
C. Clear urine
D. Urinary frequency without discomfort
Answer: B. Bladder distention
Rationale: Urinary retention commonly causes bladder distention, discomfort,
urgency, and small amounts of urine output.
8. A nurse is teaching a client about preventing constipation. Which
instruction is appropriate?
A. Limit fluid intake
B. Increase dietary fiber
C. Avoid physical activity
D. Use stimulant laxatives daily
Answer: B. Increase dietary fiber
Rationale: Fiber increases stool bulk and promotes regular bowel movements
when adequate fluid intake is maintained.
, 9. Which client should the nurse assess first?
A. A client requesting assistance with bathing
B. A client reporting mild constipation
C. A client with new difficulty breathing
D. A client requesting a change of linens
Answer: C. A client with new difficulty breathing
Rationale: New-onset respiratory difficulty may indicate an acute, potentially
life-threatening problem and requires immediate assessment.
10. Which intervention is appropriate for a client at risk for falls?
A. Keep the bed in the highest position
B. Keep frequently used items within reach
C. Encourage the client to walk without assistance
D. Keep the room dark at night
Answer: B. Keep frequently used items within reach
Rationale: Keeping needed items within reach reduces unnecessary attempts
to get out of bed and decreases fall risk.
11. A client is using a cane. Which instruction should the nurse provide?
A. Hold the cane on the stronger side
B. Hold the cane on the weaker side
C. Move the unaffected leg first every time
D. Keep the cane several feet ahead of the body
Answer: A. Hold the cane on the stronger side
Rationale: Holding the cane on the stronger side provides better support and
allows the stronger extremity to assist the weaker side.
12. Which action demonstrates proper use of a walker?
