Basic Care and Comfort NCLEX Questions and Answers with verified solutions

Basic Care and Comfort NCLEX Questions and Answers with verified solutions A 32-year-old female with no significant history comes to the clinic for a routine check-up. Where is the most appropriate spot to measure this client's pulse? a. Apical b. Femoral c. Radial d. Carotid - ANS- c. Radial For a client with an uncomplicated medical history, taking a radial pulse is appropriate. An apical pulse is appropriate for clients taking cardiovascular medications, such as Digoxin. A carotid pulse is appropriate for emergency situations, such as cardiac arrest. Taking a femoral pulse is not necessary and can be considered an invasion of privacy. A client comes to the clinic, complaining of severe gastrointestinal distress. Which abdominal physical assessment step does the nurse do first? a. percussion b. palpation c. inspection d. auscultation - ANS- c. inspection The correct sequence for physical assessment of the ABDOMEN is as follows: 1) inspect, 2) auscultate, 3) percuss, 4) palpate The order is different from the physical assessment of the body systems, which is Inspect, Palpate, Percuss, Auscultate A client has a pressure ulcer on the sacrum. While assessing it, the nurse observes that it has partial thickness, loss of dermis, and a red-pink wound bed. Which stage will the nurse assign this pressure ulcer? a. Stage III b. Stage II c. Stage I d. Stage IV - ANS- b. Stage II Stage I pressure ulcers have intact skin with a reddened area that may be firm and painful. Stage II pressure ulcers are indicated by partial thickness, loss of dermis, and a red-pink wound bed. Stage III pressure ulcers have full-thickness skin loss and may contain slough, visible subcutaneous tissue, and tunneling. Stage IV pressure ulcers have full-thickness skin loss and exposed muscle, bone, or tendons. A client returns to the unit after abdominal surgery. While monitoring the client, the nurse observes a moderate amount of red blood on the dressing. The nurse will document this type of wound drainage as a. Purulent b. Sanguineous c. Serosanguineous d. Serous - ANS- b. Sanguineous The word comes from the Latin, meaning "blood." Wound drainage is described by type, color, amount, and odor. Types of drainage are: 1. Serous: clear and thin; may be present in a healthy, healing wound. 2. Serosanguineous: containing blood; may also be present in a healthy, healing wound. 3. Sanguineous: primarily blood. 4. Purulent: thick, white, and pus-like; may be indicative of infection and should be cultured A client with a diagnosis of congestive heart failure (CHF) is placed on strict intake and output (I&O). The unlicensed assistive personnel (UAP) records the client's intake at lunch as 8 oz. of black coffee, 6 oz. of orange juice, 4 oz. of lime jello, and 4 oz. of vanilla pudding. What is the client's intake? a. 240 mL b. 420 mL c. 660 mL d. 540 mL - ANS- d. 540 mL Intake is considered any food that is liquid at room temperature. The client's intake is 8+6+4=18 fluid ounces. 1 fluid ounce = 30 mL, so 18 ounces = 540 mL. Pudding is not included, because it is not a liquid at room temperature. Liquids include coffee, tea, milk, soft drinks, water, gelatin (jello), broth, ice cream, popsicles, sorbet, and nutritional supplement drinks, such as Ensure. Note: Ice chips melt to half their volume. For example, if the client receives 8 oz. of ice chips, record the intake as 4 oz. A client with a severe ankle sprain will be using crutches. Which of the following indicates that the crutches have been fitted correctly? a. The client's elbow is locked with the hand on the handgrip b. The client's axilla rests on the crutch pad when the client ambulates c. The client's axilla is at the same level as the top of the crutch d. The client's elbow is at a 30-degree angle with the hand on the handgrip - ANS- d. The client's elbow is at a 30-degree angle with the hand on the handgrip Proper crutch measurements result in the client's weight being on the hands, not the axilla. This avoids damage to the brachial plexus. The elbow should be at a 30-degree flex, not straight. The top of the crutch should be 2 to 3 finger widths lower than the axilla. A client with chronic renal failure (CRF) is learning to perform peritoneal dialysis at home. The nurse instructs the client to warm the dialyzing solution to 37 degrees Celsius so that it will a. remove toxins from the body's cells b. dilate the peritoneal blood vessels c. relax the abdominal muscles d. maintain a constant body temperature - ANS- b. dilate the peritoneal blood vessels The rationale for warming the peritoneal dialysis solution is that the warm solution helps dilate peritoneal vessels, which increases urea clearance. Warming dialyzing solution also contributes to client comfort by preventing cold sensations. A client with diabetes insipidus has urine output described as - ANS- polyuria Polyuria is a primary symptom of diabetes insipidus, with urine output more than 3 L/day. These clients have decreased or absent vasopressin secretion, which causes water loss in the urine and increased serum sodium. Anuria is the absence of urine output. Oliguria is urine output of less than 500 mL/day. Dysuria is difficult or painful urination. A client with end-stage renal disease has opted for an arteriovenous (AV) fistula for long-term treatment with hemodialysis. Following the surgical creation of the AV fistula, when will the client be able to use it for hemodialysis? a. 4-6 months b. 4-6 weeks c. 2-3 weeks d. 2-3 months - ANS- d. 2-3 months An AV fistula is a connection of an artery to a vein, created by a vascular surgeon. An AV fistula frequently requires 2 to 3 months to develop or mature before the patient can use it for long-term hemodialysis. 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? a. do a wet-to-dry dressing change b. cover with sterile gauze c. no dressing is necessary d. apply a hydrocolloid dressing - ANS- c. no dressing is necessary