NCLEX RN Basic Care & Comfort Exam 1
Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A | Instant Download Pdf
1. Oral Hygiene for the Unconscious Client
The nurse is preparing to provide oral care to an unconscious client. Which
action is most important to prevent aspiration?
A. Use a toothbrush with toothpaste and scrub all tooth surfaces vigorously.
B. Position the client in a side-lying position and have suction equipment
ready at the bedside.
C. Apply mineral oil to the lips and leave the mouth open to air dry after
rinsing.
D. Place the client supine with the head elevated 90 degrees and use a
sponge swab.
B. Position the client in a side-lying position and have suction equipment ready
at the bedside.
Rationale: An unconscious client lacks a gag reflex and is at high risk for
aspiration. Placing the client in a side-lying position allows oral secretions and
any fluid to drain out of the mouth by gravity rather than pooling in the
pharynx. Having suction equipment immediately available enables prompt
removal of secretions should the client gag or cough. Using a toothbrush is
acceptable but not the priority safety measure. Supine position with head
elevated 90 degrees still poses a risk if fluid accumulates. Mineral oil can cause
lipoid pneumonia if aspirated.
2. Assisting with Ambulation After Prolonged Bed Rest
A client who has been on bed rest for five days is to begin ambulation.
Which assessment finding requires the nurse to postpone the activity and
, notify the healthcare provider?
A. Client reports feeling slightly lightheaded when sitting on the edge of the
bed.
B. Pedal pulses are 2+ bilaterally and capillary refill is less than 3 seconds.
C. Orthostatic blood pressure measurements reveal a drop of 25 mm Hg
systolic upon standing.
D. Client states, “I am a little tired today but willing to try.”
C. Orthostatic blood pressure measurements reveal a drop of 25 mm Hg systolic
upon standing.
Rationale: A systolic drop of 20 mm Hg or more, or a diastolic drop of 10 mm Hg
or more, with associated symptoms indicates orthostatic hypotension.
Ambulating a client with significant orthostasis increases fall risk and may
compromise cerebral perfusion. The nurse should keep the client in bed, raise
the side rails, and contact the provider. Transient lightheadedness during initial
dangling is common and can be managed by gradual position changes. Normal
pedal pulses and capillary refill are encouraging. Fatigue alone is not a
contraindication.
3. Preventing Skin Breakdown in an Incontinent Client
A client with urinary incontinence has been placed on a toileting schedule.
What additional intervention best protects the skin from breakdown?
A. Apply a moisture barrier cream after each episode of incontinence.
B. Use a heat lamp to dry the perineal area after cleansing.
C. Place an absorbent pad under the client without changing it until
saturated.
D. Wash the skin with hot water and antibacterial soap twice daily.
A. Apply a moisture barrier cream after each episode of incontinence.
Rationale: Prolonged exposure to urine and stool leads to maceration and
chemical irritation, increasing the risk of moisture-associated skin damage. A
moisture barrier cream or ointment containing zinc oxide, dimethicone, or
petrolatum creates a protective film that repels moisture. The area should be
cleansed gently with a pH-balanced cleanser, dried by patting, and the barrier
,applied. Heat lamps can burn fragile skin. Pads should be changed promptly
when wet. Hot water and harsh soaps strip natural oils and dry the skin.
4. Providing a Bed Bath to a Client with Dementia
During a bed bath, a client with moderate dementia becomes agitated and
strikes out at the nurse. What is the nurse’s best response?
A. Restrain the client’s hands with soft mitts and continue the bath quickly.
B. Stop the bath, step back to ensure safety, and speak in a calm, reassuring
tone.
C. Call for additional staff to hold the client down while completing the
bath.
D. Ignore the behavior and continue washing the client while humming
softly.
B. Stop the bath, step back to ensure safety, and speak in a calm, reassuring
tone.
Rationale: Agitation during personal care is common in dementia due to fear,
discomfort, or inability to understand the situation. The priority is safety for
both client and nurse. Stopping the procedure, creating physical space, and
using a calm, nonthreatening voice can de-escalate the situation. The bath can
be resumed later or modified. Physical restraints or holding the client down can
escalate agitation and cause injury. Ignoring the behavior does not address the
client’s distress and may reinforce fear.
5. Selecting a Diet to Promote Wound Healing
The nurse is reinforcing dietary teaching for a client with a large pressure
injury. Which food choice indicates the client understands the need for a
high-protein, high-vitamin C diet?
A. Scrambled eggs, a glass of orange juice, and a strawberry yogurt cup.
B. Buttered toast with jam, tea, and a banana.
C. A green salad with lettuce, cucumber, and low-fat dressing.
D. A bowl of cream of wheat, black coffee, and applesauce.
A. Scrambled eggs, a glass of orange juice, and a strawberry yogurt cup.
Rationale: Wound healing requires adequate protein to rebuild tissue and
, vitamin C for collagen synthesis. Eggs and yogurt are excellent sources of
protein, while orange juice and strawberries are rich in vitamin C. Toast and jam
provide mostly carbohydrates; a green salad lacks protein; cream of wheat and
applesauce provide minimal protein. The meal in option A addresses both
macronutrient and micronutrient needs for tissue repair.
6. Inserting a Nasogastric Tube for Enteral Feeding
The nurse is inserting a nasogastric (NG) tube. Which action best ensures
correct placement before initiating tube feeding?
A. Inject 30 mL of air into the tube while auscultating over the epigastrium.
B. Check the pH of aspirated gastric contents and confirm with an
abdominal radiograph.
C. Submerge the end of the tube in water and observe for continuous
bubbling.
D. Measure the external length of the tube from the naris to the earlobe to
the xiphoid.
B. Check the pH of aspirated gastric contents and confirm with an abdominal
radiograph.
Rationale: The gold standard for verifying initial NG tube placement is
radiographic confirmation. Checking the pH of aspirated gastric fluid (pH ≤ 5.5)
provides additional bedside evidence. Auscultation of air insufflation is
unreliable because sounds can be transmitted to the epigastrium even if the
tube is in the lung or esophagus. Bubbling in water indicates the tube may be in
the airway. External measurement estimates insertion length but does not verify
final placement.
7. Promoting Sleep in the Hospital Environment
A client repeatedly complains of inability to sleep due to noise and frequent
interruptions. Which nursing intervention is most effective in promoting a
restful environment?
A. Administer the prescribed sedative one hour earlier than scheduled.
B. Cluster care activities to allow a 90- to 120-minute uninterrupted rest
period.
Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A | Instant Download Pdf
1. Oral Hygiene for the Unconscious Client
The nurse is preparing to provide oral care to an unconscious client. Which
action is most important to prevent aspiration?
A. Use a toothbrush with toothpaste and scrub all tooth surfaces vigorously.
B. Position the client in a side-lying position and have suction equipment
ready at the bedside.
C. Apply mineral oil to the lips and leave the mouth open to air dry after
rinsing.
D. Place the client supine with the head elevated 90 degrees and use a
sponge swab.
B. Position the client in a side-lying position and have suction equipment ready
at the bedside.
Rationale: An unconscious client lacks a gag reflex and is at high risk for
aspiration. Placing the client in a side-lying position allows oral secretions and
any fluid to drain out of the mouth by gravity rather than pooling in the
pharynx. Having suction equipment immediately available enables prompt
removal of secretions should the client gag or cough. Using a toothbrush is
acceptable but not the priority safety measure. Supine position with head
elevated 90 degrees still poses a risk if fluid accumulates. Mineral oil can cause
lipoid pneumonia if aspirated.
2. Assisting with Ambulation After Prolonged Bed Rest
A client who has been on bed rest for five days is to begin ambulation.
Which assessment finding requires the nurse to postpone the activity and
, notify the healthcare provider?
A. Client reports feeling slightly lightheaded when sitting on the edge of the
bed.
B. Pedal pulses are 2+ bilaterally and capillary refill is less than 3 seconds.
C. Orthostatic blood pressure measurements reveal a drop of 25 mm Hg
systolic upon standing.
D. Client states, “I am a little tired today but willing to try.”
C. Orthostatic blood pressure measurements reveal a drop of 25 mm Hg systolic
upon standing.
Rationale: A systolic drop of 20 mm Hg or more, or a diastolic drop of 10 mm Hg
or more, with associated symptoms indicates orthostatic hypotension.
Ambulating a client with significant orthostasis increases fall risk and may
compromise cerebral perfusion. The nurse should keep the client in bed, raise
the side rails, and contact the provider. Transient lightheadedness during initial
dangling is common and can be managed by gradual position changes. Normal
pedal pulses and capillary refill are encouraging. Fatigue alone is not a
contraindication.
3. Preventing Skin Breakdown in an Incontinent Client
A client with urinary incontinence has been placed on a toileting schedule.
What additional intervention best protects the skin from breakdown?
A. Apply a moisture barrier cream after each episode of incontinence.
B. Use a heat lamp to dry the perineal area after cleansing.
C. Place an absorbent pad under the client without changing it until
saturated.
D. Wash the skin with hot water and antibacterial soap twice daily.
A. Apply a moisture barrier cream after each episode of incontinence.
Rationale: Prolonged exposure to urine and stool leads to maceration and
chemical irritation, increasing the risk of moisture-associated skin damage. A
moisture barrier cream or ointment containing zinc oxide, dimethicone, or
petrolatum creates a protective film that repels moisture. The area should be
cleansed gently with a pH-balanced cleanser, dried by patting, and the barrier
,applied. Heat lamps can burn fragile skin. Pads should be changed promptly
when wet. Hot water and harsh soaps strip natural oils and dry the skin.
4. Providing a Bed Bath to a Client with Dementia
During a bed bath, a client with moderate dementia becomes agitated and
strikes out at the nurse. What is the nurse’s best response?
A. Restrain the client’s hands with soft mitts and continue the bath quickly.
B. Stop the bath, step back to ensure safety, and speak in a calm, reassuring
tone.
C. Call for additional staff to hold the client down while completing the
bath.
D. Ignore the behavior and continue washing the client while humming
softly.
B. Stop the bath, step back to ensure safety, and speak in a calm, reassuring
tone.
Rationale: Agitation during personal care is common in dementia due to fear,
discomfort, or inability to understand the situation. The priority is safety for
both client and nurse. Stopping the procedure, creating physical space, and
using a calm, nonthreatening voice can de-escalate the situation. The bath can
be resumed later or modified. Physical restraints or holding the client down can
escalate agitation and cause injury. Ignoring the behavior does not address the
client’s distress and may reinforce fear.
5. Selecting a Diet to Promote Wound Healing
The nurse is reinforcing dietary teaching for a client with a large pressure
injury. Which food choice indicates the client understands the need for a
high-protein, high-vitamin C diet?
A. Scrambled eggs, a glass of orange juice, and a strawberry yogurt cup.
B. Buttered toast with jam, tea, and a banana.
C. A green salad with lettuce, cucumber, and low-fat dressing.
D. A bowl of cream of wheat, black coffee, and applesauce.
A. Scrambled eggs, a glass of orange juice, and a strawberry yogurt cup.
Rationale: Wound healing requires adequate protein to rebuild tissue and
, vitamin C for collagen synthesis. Eggs and yogurt are excellent sources of
protein, while orange juice and strawberries are rich in vitamin C. Toast and jam
provide mostly carbohydrates; a green salad lacks protein; cream of wheat and
applesauce provide minimal protein. The meal in option A addresses both
macronutrient and micronutrient needs for tissue repair.
6. Inserting a Nasogastric Tube for Enteral Feeding
The nurse is inserting a nasogastric (NG) tube. Which action best ensures
correct placement before initiating tube feeding?
A. Inject 30 mL of air into the tube while auscultating over the epigastrium.
B. Check the pH of aspirated gastric contents and confirm with an
abdominal radiograph.
C. Submerge the end of the tube in water and observe for continuous
bubbling.
D. Measure the external length of the tube from the naris to the earlobe to
the xiphoid.
B. Check the pH of aspirated gastric contents and confirm with an abdominal
radiograph.
Rationale: The gold standard for verifying initial NG tube placement is
radiographic confirmation. Checking the pH of aspirated gastric fluid (pH ≤ 5.5)
provides additional bedside evidence. Auscultation of air insufflation is
unreliable because sounds can be transmitted to the epigastrium even if the
tube is in the lung or esophagus. Bubbling in water indicates the tube may be in
the airway. External measurement estimates insertion length but does not verify
final placement.
7. Promoting Sleep in the Hospital Environment
A client repeatedly complains of inability to sleep due to noise and frequent
interruptions. Which nursing intervention is most effective in promoting a
restful environment?
A. Administer the prescribed sedative one hour earlier than scheduled.
B. Cluster care activities to allow a 90- to 120-minute uninterrupted rest
period.
