NCLEX Basic Care And Comfort
UPDATED Actual Exam Questions and
CORRECT Answers
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? - CORRECT ANSWER✔✔- 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? - CORRECT ANSWER✔✔- 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? - CORRECT ANSWER✔✔- 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? - CORRECT ANSWER✔✔-
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? - CORRECT
ANSWER✔✔- 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. -
CORRECT ANSWER✔✔- 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? - CORRECT
ANSWER✔✔- 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? - CORRECT ANSWER✔✔- 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? -
CORRECT ANSWER✔✔- 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? -
CORRECT ANSWER✔✔- honey-colored, crusted lesions
For a client with anorexia nervosa, which goal takes the highest priority? - CORRECT
ANSWER✔✔- 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? - CORRECT ANSWER✔✔-
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? - CORRECT ANSWER✔✔- "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? - CORRECT ANSWER✔✔- 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? - CORRECT ANSWER✔✔- 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. - CORRECT ANSWER✔✔- 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? - CORRECT ANSWER✔✔- 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? - CORRECT ANSWER✔✔- Behavioral
interventions including sleep-hygiene measures are often effective in treating sleep
disturbance.
UPDATED Actual Exam Questions and
CORRECT Answers
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? - CORRECT ANSWER✔✔- 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? - CORRECT ANSWER✔✔- 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? - CORRECT ANSWER✔✔- 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? - CORRECT ANSWER✔✔-
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? - CORRECT
ANSWER✔✔- 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. -
CORRECT ANSWER✔✔- 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? - CORRECT
ANSWER✔✔- 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? - CORRECT ANSWER✔✔- 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? -
CORRECT ANSWER✔✔- 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? -
CORRECT ANSWER✔✔- honey-colored, crusted lesions
For a client with anorexia nervosa, which goal takes the highest priority? - CORRECT
ANSWER✔✔- 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? - CORRECT ANSWER✔✔-
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? - CORRECT ANSWER✔✔- "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? - CORRECT ANSWER✔✔- 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? - CORRECT ANSWER✔✔- 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. - CORRECT ANSWER✔✔- 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? - CORRECT ANSWER✔✔- 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? - CORRECT ANSWER✔✔- Behavioral
interventions including sleep-hygiene measures are often effective in treating sleep
disturbance.
