NCLEX basic care and comfort Exam Prep Questions And Answers
(202472025)
A client with schizophrenia is mute, can't perform activities of daily living, and stares out the
window for hours. What is the nurse's first priority? - ✔✔Assist the client with feeding.
During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which intervention
would be most appropriate to institute? - ✔✔keeping extraneous noise to a minimum; A child in
the acute stage of meningitis is irritable and hypersensitive to loud noise and light.
Which action will be most helpful to the nurse when determining the need for oxygen therapy in a
client with chronic obstructive pulmonary disease? - ✔✔Use a pulse oximeter to determine oxygen
saturation.
The nurse finds it difficult to relieve a client's pain satisfactorily. Which measure should the nurse
take next when continuing efforts to promote comfort? - ✔✔Increase the client's confidence in the
nurse.
A typically developing preschool child is experiencing pain after an appendectomy. Which data
collection tool is the most appropriate for the nurse use to assess the pain? - ✔✔FACES Pain
Rating Scale; The nurse should use the FACES pain rating scale for children age 3 or older. The
visual analog and numerical scales are used preferred with adults or older children who count well.
The faces, legs, activity, cry, consolability (FLACC) scale is a behavioral scale that is appropriate
for very small children or nonverbal children.
A client has an order for a clear liquid diet. The nurse is assisting the client to complete a menu.
Which item would be appropriate for the client to order? Select all that apply. - ✔✔apple juice
broth
tea;
A clear liquid diet includes foods that are clear (that you can see through) and are liquid at room
temperature.
A client is 2 days postoperative of a hip replacement. The prescriber removed the gauze dressing
and gave the patient and nurse instructions to keep the site open to air. In the afternoon, the nurse
observed the client rubbing an oil on the surgical site. What is likely the client's rationale regarding
the application of the complementary oil? - ✔✔Tea tree oil has antibacterial properties; Tea tree
oil is an alternative therapy that has antifungal and antibacterial uses. Clients use it to treat burns,
,insect bites, irritated skin, and acne. The nurse should review the prescriber's instructions with the
client and also call the prescriber to report the tea tree oil application on the surgical site.
A nurse is caring for a 3-year-old child following the removal of a Wilms' tumor. The parent states
that the child is in pain, and requests pain medication. What is the nurse's priority in regard to this
parent's request? - ✔✔Use the Faces Pain Scale to assess the child's degree of pain.
The nurse is observing a student nurse perform an irrigation of a client's nasogastric (NG) tube.
Which action by the student nurse would cause the nurse to stop the procedure? - ✔✔The student
nurse irrigates the NG tube through the blue air vent port; The student nurse would not want to
instill fluid through the blue air vent port - this is reserved for air only and is a way to decrease
pressure that can build up into the stomach when suction is used. The student nurse should wear
clean not sterile gloves because it is not a sterile procedure. The student nurse would disconnect
the suction tubing in order to attach the syringe and can use gravity versus pushing the fluid in to
instill it.
When assessing a child for impetigo, the nurse expects which assessment findings? - ✔✔honey-
colored, crusted lesions
For a client with anorexia nervosa, which goal takes the highest priority? - ✔✔The client will
establish adequate daily nutritional intake.
A client is in the eighth month of pregnancy. To enhance cardiac output and renal function, the
nurse should advise the client to use which body position? - ✔✔left lateral; The left lateral position
shifts the enlarged uterus away from the vena cava and aorta, enhancing cardiac output, kidney
perfusion, and kidney function.
A client is learning about caring for an ileostomy. Which statement would indicate that the client
understands how to care for the ileostomy pouch? - ✔✔"I'll empty my pouch when it is about one-
third full."; The pouch should be emptied when it is about one-third full to prevent the pouch's
weight from breaking the seal.The client with an ileostomy must wear a pouch at all times to collect
stool.The client should change the pouch at a time when the stoma is least likely to function; 2 to
4 hours after a meal is generally the most appropriate time.A pouch can be worn for 3 to 7 days
before being changed.
A nurse encourages a client with an immunologic disorder to eat a nutritionally balanced diet to
promote optimal immunologic function. Which snacks have the greatest probability of stimulating
, autoimmunity? - ✔✔potato chips and chocolate milk shakes; A diet containing excessive fat, such
as that found in potato chips and milk shakes, seems to contribute to autoimmunity — overreaction
of the body against constituents of its own tissues.
After having transurethral resection of the prostate (TURP), a client returns to the unit with a three-
way indwelling urinary catheter and continuous closed bladder irrigation. Which finding suggests
that the client's catheter is occluded? - ✔✔The client reports bladder spasms and the urge to void;
Reports of bladder spasms and the urge to void suggest that a blood clot may be occluding the
catheter. After TURP, urine normally appears red to pink, and normal saline irrigant usually is
infused at a rate of 40 to 60 drops/minute or according to facility protocol. The amount of returned
fluid (1,200 ml) should correspond to the amount of instilled fluid, plus the client's urine output
(1,000 ml + 200 ml), which reflects catheter patency.
The nurse is preparing to initiate enteral feeding through a percutaneous endoscopic gastrostomy
(PEG) tube. What interventions will the nurse include in the client's plan of care? Select all that
apply. - ✔✔Change tubing and bag every 24 hours.
Ensure patency of the tube prior to enteral feedings; The PEG tube should be flushed in between
every feeding and access. Formula should not hang longer than 4 to 8 hours. Initial feedings should
start out slowly, monitor client comfort, and change tubing/bag every 24 hours. Verification of
patency prior to each feeding is essential to prevent aspiration.
A client reports an inability to sleep while on the medical unit. Which intervention should the nurse
perform first? - ✔✔Inquire about the client's sleeping habits.
The parent of a child with autism tells the nurse that her child is only sleeping 2 to 3 hours per
night. When educating the parent about treatment for the child's sleep disturbance, the nurse should
include what information? - ✔✔Behavioral interventions including sleep-hygiene measures are
often effective in treating sleep disturbance.
During a routine prenatal visit, a pregnant client reports constipation, and the nurse teaches her
how to relieve it. Which statement indicates the client's understanding of the nurse's instructions?
- ✔✔"I'll increase my intake of unrefined grains."; To increase peristalsis and relieve constipation,
the client should increase her intake of high-fiber foods (such as green, leafy vegetables; unrefined
grains; and fruits) and fluids.
After instruction of a primigravid client at 8 weeks' gestation about measures to overcome early
morning nausea and vomiting, which client statement indicates the need for additional teaching? -
(202472025)
A client with schizophrenia is mute, can't perform activities of daily living, and stares out the
window for hours. What is the nurse's first priority? - ✔✔Assist the client with feeding.
During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which intervention
would be most appropriate to institute? - ✔✔keeping extraneous noise to a minimum; A child in
the acute stage of meningitis is irritable and hypersensitive to loud noise and light.
Which action will be most helpful to the nurse when determining the need for oxygen therapy in a
client with chronic obstructive pulmonary disease? - ✔✔Use a pulse oximeter to determine oxygen
saturation.
The nurse finds it difficult to relieve a client's pain satisfactorily. Which measure should the nurse
take next when continuing efforts to promote comfort? - ✔✔Increase the client's confidence in the
nurse.
A typically developing preschool child is experiencing pain after an appendectomy. Which data
collection tool is the most appropriate for the nurse use to assess the pain? - ✔✔FACES Pain
Rating Scale; The nurse should use the FACES pain rating scale for children age 3 or older. The
visual analog and numerical scales are used preferred with adults or older children who count well.
The faces, legs, activity, cry, consolability (FLACC) scale is a behavioral scale that is appropriate
for very small children or nonverbal children.
A client has an order for a clear liquid diet. The nurse is assisting the client to complete a menu.
Which item would be appropriate for the client to order? Select all that apply. - ✔✔apple juice
broth
tea;
A clear liquid diet includes foods that are clear (that you can see through) and are liquid at room
temperature.
A client is 2 days postoperative of a hip replacement. The prescriber removed the gauze dressing
and gave the patient and nurse instructions to keep the site open to air. In the afternoon, the nurse
observed the client rubbing an oil on the surgical site. What is likely the client's rationale regarding
the application of the complementary oil? - ✔✔Tea tree oil has antibacterial properties; Tea tree
oil is an alternative therapy that has antifungal and antibacterial uses. Clients use it to treat burns,
,insect bites, irritated skin, and acne. The nurse should review the prescriber's instructions with the
client and also call the prescriber to report the tea tree oil application on the surgical site.
A nurse is caring for a 3-year-old child following the removal of a Wilms' tumor. The parent states
that the child is in pain, and requests pain medication. What is the nurse's priority in regard to this
parent's request? - ✔✔Use the Faces Pain Scale to assess the child's degree of pain.
The nurse is observing a student nurse perform an irrigation of a client's nasogastric (NG) tube.
Which action by the student nurse would cause the nurse to stop the procedure? - ✔✔The student
nurse irrigates the NG tube through the blue air vent port; The student nurse would not want to
instill fluid through the blue air vent port - this is reserved for air only and is a way to decrease
pressure that can build up into the stomach when suction is used. The student nurse should wear
clean not sterile gloves because it is not a sterile procedure. The student nurse would disconnect
the suction tubing in order to attach the syringe and can use gravity versus pushing the fluid in to
instill it.
When assessing a child for impetigo, the nurse expects which assessment findings? - ✔✔honey-
colored, crusted lesions
For a client with anorexia nervosa, which goal takes the highest priority? - ✔✔The client will
establish adequate daily nutritional intake.
A client is in the eighth month of pregnancy. To enhance cardiac output and renal function, the
nurse should advise the client to use which body position? - ✔✔left lateral; The left lateral position
shifts the enlarged uterus away from the vena cava and aorta, enhancing cardiac output, kidney
perfusion, and kidney function.
A client is learning about caring for an ileostomy. Which statement would indicate that the client
understands how to care for the ileostomy pouch? - ✔✔"I'll empty my pouch when it is about one-
third full."; The pouch should be emptied when it is about one-third full to prevent the pouch's
weight from breaking the seal.The client with an ileostomy must wear a pouch at all times to collect
stool.The client should change the pouch at a time when the stoma is least likely to function; 2 to
4 hours after a meal is generally the most appropriate time.A pouch can be worn for 3 to 7 days
before being changed.
A nurse encourages a client with an immunologic disorder to eat a nutritionally balanced diet to
promote optimal immunologic function. Which snacks have the greatest probability of stimulating
, autoimmunity? - ✔✔potato chips and chocolate milk shakes; A diet containing excessive fat, such
as that found in potato chips and milk shakes, seems to contribute to autoimmunity — overreaction
of the body against constituents of its own tissues.
After having transurethral resection of the prostate (TURP), a client returns to the unit with a three-
way indwelling urinary catheter and continuous closed bladder irrigation. Which finding suggests
that the client's catheter is occluded? - ✔✔The client reports bladder spasms and the urge to void;
Reports of bladder spasms and the urge to void suggest that a blood clot may be occluding the
catheter. After TURP, urine normally appears red to pink, and normal saline irrigant usually is
infused at a rate of 40 to 60 drops/minute or according to facility protocol. The amount of returned
fluid (1,200 ml) should correspond to the amount of instilled fluid, plus the client's urine output
(1,000 ml + 200 ml), which reflects catheter patency.
The nurse is preparing to initiate enteral feeding through a percutaneous endoscopic gastrostomy
(PEG) tube. What interventions will the nurse include in the client's plan of care? Select all that
apply. - ✔✔Change tubing and bag every 24 hours.
Ensure patency of the tube prior to enteral feedings; The PEG tube should be flushed in between
every feeding and access. Formula should not hang longer than 4 to 8 hours. Initial feedings should
start out slowly, monitor client comfort, and change tubing/bag every 24 hours. Verification of
patency prior to each feeding is essential to prevent aspiration.
A client reports an inability to sleep while on the medical unit. Which intervention should the nurse
perform first? - ✔✔Inquire about the client's sleeping habits.
The parent of a child with autism tells the nurse that her child is only sleeping 2 to 3 hours per
night. When educating the parent about treatment for the child's sleep disturbance, the nurse should
include what information? - ✔✔Behavioral interventions including sleep-hygiene measures are
often effective in treating sleep disturbance.
During a routine prenatal visit, a pregnant client reports constipation, and the nurse teaches her
how to relieve it. Which statement indicates the client's understanding of the nurse's instructions?
- ✔✔"I'll increase my intake of unrefined grains."; To increase peristalsis and relieve constipation,
the client should increase her intake of high-fiber foods (such as green, leafy vegetables; unrefined
grains; and fruits) and fluids.
After instruction of a primigravid client at 8 weeks' gestation about measures to overcome early
morning nausea and vomiting, which client statement indicates the need for additional teaching? -
