NCLEX RN Basic Care & Comfort Exam 2
Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A | Instant Download Pdf
Mobility and Contracture Prevention
1. The nurse is planning care for an immobile client. Which device best
prevents plantar flexion contracture?
A. Trochanter roll
B. Footboard
C. Hand roll
D. Abduction pillow
Answer: B
Rationale: A footboard maintains the feet in dorsiflexion, preventing foot
drop (plantar flexion contracture). A trochanter roll prevents external
rotation of the hips, a hand roll prevents hand contractures, and an
abduction pillow keeps the hips in abduction, commonly after hip surgery.
None of these address ankle positioning.
Post Hip Arthroplasty Positioning
2. A client had a total hip replacement via a posterior approach. Which
position should the nurse teach the client to avoid to prevent dislocation?
A. Supine with legs slightly abducted
B. Side-lying with an abduction pillow between the legs
C. High Fowler’s with hips flexed more than 90 degrees
D. Semi-Fowler’s with knees slightly flexed
Answer: C
Rationale: After a posterior hip replacement, hip flexion beyond 90
degrees, adduction, and internal rotation must be avoided. Sitting in high
, Fowler’s with hips flexed greater than 90 degrees places extreme stress on
the posterior capsule and risks dislocation. Supine with abduction, side-
lying with a pillow between legs, and semi-Fowler’s with knees slightly
flexed maintain safe alignment.
Logrolling a Client with Spinal Injury
3. The nurse prepares to turn a client who had a spinal fusion. Which
technique should be used to maintain spinal alignment?
A. Tilt the client to one side using the bed rail
B. Place the bed in reverse Trendelenburg and turn
C. Use a drawsheet to lift and turn the client as a unit
D. Have the client grasp the side rail and pull herself over
Answer: C
Rationale: Logrolling using a drawsheet keeps the spine in a straight line
without twisting. Tilting or allowing the client to pull would cause
rotation, endangering the fusion. Reverse Trendelenburg does not protect
spinal alignment.
Trochanter Roll Application
4. The nurse is caring for an unconscious client on bed rest. Where should a
trochanter roll be placed?
A. Along the lateral aspect of the thigh from hip to knee
B. Under the heels to float them off the bed
C. Behind the knees to slightly flex them
D. Across the lower abdomen to prevent sacral pressure
Answer: A
Rationale: A trochanter roll is placed from the iliac crest to mid-thigh
along the lateral aspect of the leg to prevent external rotation of the hip.
Heel protectors prevent heel pressure, a knee roll keeps knees slightly
flexed, and an abdominal pad does not prevent hip rotation.
Preventing Hand Contractures
, 5. A client with prolonged immobility is at risk for hand contractures. Which
intervention should the nurse implement?
A. Apply a footboard
B. Place a rolled washcloth in the palm
C. Use an abduction pillow between the hands
D. Position the hands in a dependent position
Answer: B
Rationale: A hand roll or rolled washcloth maintains the hand in a
functional position, preventing flexion contractures of the fingers. A
footboard prevents foot drop, an abduction pillow separates the legs, and
dependent hand positioning promotes edema, not contracture prevention.
Preventing Aspiration During Feeding
6. The nurse is assisting a client with right-sided weakness during meals. What
position is most important to reduce aspiration risk?
A. Lying on the left side
B. High Fowler’s with the chin slightly tucked
C. Flat with the head turned to the left
D. Semi-Fowler’s with the neck hyperextended
Answer: B
Rationale: An upright high Fowler’s position with the chin slightly tucked
closes the airway and directs food toward the esophagus, reducing
aspiration risk. Lying flat or semi-Fowler’s with hyperextension opens the
airway and increases aspiration potential. Side-lying alone does not
protect the airway as effectively.
Positioning a Hemiplegic Client
7. A client with left-sided hemiplegia is positioned in bed. Which action by the
nurse best prevents shoulder subluxation?
A. Keep the left arm adducted and internally rotated
B. Place a small pillow under the left axilla and support the arm on a pillow
C. Rest the left arm across the abdomen without support
D. Elevate the left arm on one pillow behind the head
, Answer: B
Rationale: Supporting the affected arm on a pillow with a small axillary
roll maintains slight abduction and neutral rotation, preventing shoulder
subluxation. Adduction and internal rotation can cause contractures;
resting the arm across the abdomen or behind the head does not provide
adequate joint support.
Moving Client Up in Bed with Drawsheet
8. Two nurses are repositioning an immobile client up in bed using a
drawsheet. Which action reduces friction and shear?
A. Pulling the client without lifting
B. Asking the client to push with her feet
C. Using a lift sheet and lifting slightly rather than dragging
D. Placing the bed in Trendelenburg position
Answer: C
Rationale: Lifting the client slightly with a drawsheet minimizes friction
and shear forces that damage skin. Pulling without lifting, pushing with
feet, or using Trendelenburg increases shear and may cause injury.
Mechanical Lift Use
9. The nurse needs to transfer a bariatric client from the bed to a chair. Which
equipment choice is safest for both client and staff?
A. A transfer belt and two staff members
B. A slide board with the bed slightly elevated
C. A full-body mechanical lift with an appropriate sling
D. A stand-assist lift and one staff member
Answer: C
Rationale: A full-body mechanical lift minimizes risk of injury to both the
client and caregivers when transferring a dependent bariatric client. A
transfer belt or slide board requires the client to bear weight and may be
unsafe. A stand-assist lift requires the client to have weight-bearing
ability, which may be lacking.
Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A | Instant Download Pdf
Mobility and Contracture Prevention
1. The nurse is planning care for an immobile client. Which device best
prevents plantar flexion contracture?
A. Trochanter roll
B. Footboard
C. Hand roll
D. Abduction pillow
Answer: B
Rationale: A footboard maintains the feet in dorsiflexion, preventing foot
drop (plantar flexion contracture). A trochanter roll prevents external
rotation of the hips, a hand roll prevents hand contractures, and an
abduction pillow keeps the hips in abduction, commonly after hip surgery.
None of these address ankle positioning.
Post Hip Arthroplasty Positioning
2. A client had a total hip replacement via a posterior approach. Which
position should the nurse teach the client to avoid to prevent dislocation?
A. Supine with legs slightly abducted
B. Side-lying with an abduction pillow between the legs
C. High Fowler’s with hips flexed more than 90 degrees
D. Semi-Fowler’s with knees slightly flexed
Answer: C
Rationale: After a posterior hip replacement, hip flexion beyond 90
degrees, adduction, and internal rotation must be avoided. Sitting in high
, Fowler’s with hips flexed greater than 90 degrees places extreme stress on
the posterior capsule and risks dislocation. Supine with abduction, side-
lying with a pillow between legs, and semi-Fowler’s with knees slightly
flexed maintain safe alignment.
Logrolling a Client with Spinal Injury
3. The nurse prepares to turn a client who had a spinal fusion. Which
technique should be used to maintain spinal alignment?
A. Tilt the client to one side using the bed rail
B. Place the bed in reverse Trendelenburg and turn
C. Use a drawsheet to lift and turn the client as a unit
D. Have the client grasp the side rail and pull herself over
Answer: C
Rationale: Logrolling using a drawsheet keeps the spine in a straight line
without twisting. Tilting or allowing the client to pull would cause
rotation, endangering the fusion. Reverse Trendelenburg does not protect
spinal alignment.
Trochanter Roll Application
4. The nurse is caring for an unconscious client on bed rest. Where should a
trochanter roll be placed?
A. Along the lateral aspect of the thigh from hip to knee
B. Under the heels to float them off the bed
C. Behind the knees to slightly flex them
D. Across the lower abdomen to prevent sacral pressure
Answer: A
Rationale: A trochanter roll is placed from the iliac crest to mid-thigh
along the lateral aspect of the leg to prevent external rotation of the hip.
Heel protectors prevent heel pressure, a knee roll keeps knees slightly
flexed, and an abdominal pad does not prevent hip rotation.
Preventing Hand Contractures
, 5. A client with prolonged immobility is at risk for hand contractures. Which
intervention should the nurse implement?
A. Apply a footboard
B. Place a rolled washcloth in the palm
C. Use an abduction pillow between the hands
D. Position the hands in a dependent position
Answer: B
Rationale: A hand roll or rolled washcloth maintains the hand in a
functional position, preventing flexion contractures of the fingers. A
footboard prevents foot drop, an abduction pillow separates the legs, and
dependent hand positioning promotes edema, not contracture prevention.
Preventing Aspiration During Feeding
6. The nurse is assisting a client with right-sided weakness during meals. What
position is most important to reduce aspiration risk?
A. Lying on the left side
B. High Fowler’s with the chin slightly tucked
C. Flat with the head turned to the left
D. Semi-Fowler’s with the neck hyperextended
Answer: B
Rationale: An upright high Fowler’s position with the chin slightly tucked
closes the airway and directs food toward the esophagus, reducing
aspiration risk. Lying flat or semi-Fowler’s with hyperextension opens the
airway and increases aspiration potential. Side-lying alone does not
protect the airway as effectively.
Positioning a Hemiplegic Client
7. A client with left-sided hemiplegia is positioned in bed. Which action by the
nurse best prevents shoulder subluxation?
A. Keep the left arm adducted and internally rotated
B. Place a small pillow under the left axilla and support the arm on a pillow
C. Rest the left arm across the abdomen without support
D. Elevate the left arm on one pillow behind the head
, Answer: B
Rationale: Supporting the affected arm on a pillow with a small axillary
roll maintains slight abduction and neutral rotation, preventing shoulder
subluxation. Adduction and internal rotation can cause contractures;
resting the arm across the abdomen or behind the head does not provide
adequate joint support.
Moving Client Up in Bed with Drawsheet
8. Two nurses are repositioning an immobile client up in bed using a
drawsheet. Which action reduces friction and shear?
A. Pulling the client without lifting
B. Asking the client to push with her feet
C. Using a lift sheet and lifting slightly rather than dragging
D. Placing the bed in Trendelenburg position
Answer: C
Rationale: Lifting the client slightly with a drawsheet minimizes friction
and shear forces that damage skin. Pulling without lifting, pushing with
feet, or using Trendelenburg increases shear and may cause injury.
Mechanical Lift Use
9. The nurse needs to transfer a bariatric client from the bed to a chair. Which
equipment choice is safest for both client and staff?
A. A transfer belt and two staff members
B. A slide board with the bed slightly elevated
C. A full-body mechanical lift with an appropriate sling
D. A stand-assist lift and one staff member
Answer: C
Rationale: A full-body mechanical lift minimizes risk of injury to both the
client and caregivers when transferring a dependent bariatric client. A
transfer belt or slide board requires the client to bear weight and may be
unsafe. A stand-assist lift requires the client to have weight-bearing
ability, which may be lacking.
