NSG 3100 NCLEX QUESTIONS UNIT 1
QUESTIONS WITH 100% ACCURATE ANSWERS
The nurse is preparing to provide morning care to a client. What should the nurse explain to the clients
the reason for a daily bath?
1. Assess skin integrity
2. Develop a nurse/client relationship
3. Moisturize the skin
4. Stimulate circulation - Accurate answers 4. Stimulate Circulation
Rationale 1: Giving a bath to a client will allow the nurse to assess the skin but this is not the most
important purpose.
Rationale 2: Giving a bath to a client will allow the nurse to develop a nurse/client relationship but this is
not the most important purpose.
Rationale 3: Giving a bath to a client will allow the nurse to moisturize the skin but this is not the most
important purpose.
Rationale 4: The three major reasons for a bath are to remove waste products such as perspiration,
stimulate circulation, and refresh the client.
The nurse is preparing to bath a client on the first postoperative day. Which nursing intervention should
take priority?
1. Apply lotion to the extremities.
2. Change the water when it becomes cold.
3. Raise side rails when gathering supplies.
4. Remove the soiled dressing during the bath. - Accurate answers 3. Raise side rails when
gathering supplies
Rationale 1: Applying lotion to the skin would be performed before or after, not during, the bath.
Rationale 2: Changing the water needs to be done before it becomes cold, but it is not a priority.
Rationale 3: Raising the side rails would take priority when planning care. This is a safety issue, andsafety
is second on Maslow's Hierarchy of Needs. The client is only 1 day postop and may still besedated,
posing a risk for a potential fall.
Rationale 4: A dressing change would be performed before or after, not during, the bath and only with
adoctors order.
The nurse identifies the diagnosis Self-Care Deficit related to cognitive impairment as appropriate for a
client. What should the nurse select as an expected outcome for this client?
1. The client will be able to name the staff that works on the day shift.
2. The client will eliminate safety hazards in her environment
, 3. The client, with supervision, will brush her teeth
4. The nurse will stress the importance of adequate fluid intake. - Accurate answers 3. The client,
with supervision, will brush her teeth.
Rationale 1: Cognitive impairment limits the clients ability to understand and comprehend; therefore,
naming the staff is not within the clients realm of understanding.
Rationale 2: Cognitive impairment limits the clients ability to understand and comprehend; therefore,
eliminating safety hazards is not within the clients realm of understanding.
Rationale 3: A client with cognitive impairment would be able to brush her teeth but only with
supervision. The client would not voluntarily brush her teeth without prompting from the staff.
Rationale 4: Cognitive impairment limits the clients ability to understand and comprehend; therefore,
stressing adequate fluid intake is not within the clients realm of understanding.
The nurse is caring for a client with diabetes. What should the nurse include as foot care for this client?
1. Cut toenails in a rounded shape and file.
2. Dry toes thoroughly.
3. Wash feet with water at a temperature of 90F to 98.6F.
4. Inspect feet thoroughly once a week. - Accurate answers 2. Dry toes thoroughly
Rationale 1: Toenails should be cut straight across, and nurses do not cut diabetic clients toenails. Only a
podiatrist should handle this task.
Rationale 2: Toes should be dried thoroughly after being washed to impede fungal growth and
preventmaceration.
Rationale 3: The water to wash the feet should be 100F to 110F.
Rationale 4: Feet should be inspected each day, not once a week, for early detection of any problems.
client has the nursing diagnosis Risk for Impaired Skin Integrity related to immobility. Which nursing
intervention should be identified for this clients problem?
1. Encourage the client to eat at least 40% of meals.
2. Keep linens dry and wrinkle-free.
3. Restrict fluid intake.
4. Turn client every 3 hours. - Accurate answers 2. Keep linens dry and wrinkle free.
Rationale 1: For nutritional support to promote healthy tissue, clients should consume more than 40% of
their meals.
Rationale 2: Keeping linens dry and wrinkle-free will prevent pressure areas.
Rationale 3: Fluids should not be restricted unless some other physical condition dictates. The skin
should be kept hydrated.
Rationale 4: To relieve pressure, the client should be turned every 2 hours, not every 3.
QUESTIONS WITH 100% ACCURATE ANSWERS
The nurse is preparing to provide morning care to a client. What should the nurse explain to the clients
the reason for a daily bath?
1. Assess skin integrity
2. Develop a nurse/client relationship
3. Moisturize the skin
4. Stimulate circulation - Accurate answers 4. Stimulate Circulation
Rationale 1: Giving a bath to a client will allow the nurse to assess the skin but this is not the most
important purpose.
Rationale 2: Giving a bath to a client will allow the nurse to develop a nurse/client relationship but this is
not the most important purpose.
Rationale 3: Giving a bath to a client will allow the nurse to moisturize the skin but this is not the most
important purpose.
Rationale 4: The three major reasons for a bath are to remove waste products such as perspiration,
stimulate circulation, and refresh the client.
The nurse is preparing to bath a client on the first postoperative day. Which nursing intervention should
take priority?
1. Apply lotion to the extremities.
2. Change the water when it becomes cold.
3. Raise side rails when gathering supplies.
4. Remove the soiled dressing during the bath. - Accurate answers 3. Raise side rails when
gathering supplies
Rationale 1: Applying lotion to the skin would be performed before or after, not during, the bath.
Rationale 2: Changing the water needs to be done before it becomes cold, but it is not a priority.
Rationale 3: Raising the side rails would take priority when planning care. This is a safety issue, andsafety
is second on Maslow's Hierarchy of Needs. The client is only 1 day postop and may still besedated,
posing a risk for a potential fall.
Rationale 4: A dressing change would be performed before or after, not during, the bath and only with
adoctors order.
The nurse identifies the diagnosis Self-Care Deficit related to cognitive impairment as appropriate for a
client. What should the nurse select as an expected outcome for this client?
1. The client will be able to name the staff that works on the day shift.
2. The client will eliminate safety hazards in her environment
, 3. The client, with supervision, will brush her teeth
4. The nurse will stress the importance of adequate fluid intake. - Accurate answers 3. The client,
with supervision, will brush her teeth.
Rationale 1: Cognitive impairment limits the clients ability to understand and comprehend; therefore,
naming the staff is not within the clients realm of understanding.
Rationale 2: Cognitive impairment limits the clients ability to understand and comprehend; therefore,
eliminating safety hazards is not within the clients realm of understanding.
Rationale 3: A client with cognitive impairment would be able to brush her teeth but only with
supervision. The client would not voluntarily brush her teeth without prompting from the staff.
Rationale 4: Cognitive impairment limits the clients ability to understand and comprehend; therefore,
stressing adequate fluid intake is not within the clients realm of understanding.
The nurse is caring for a client with diabetes. What should the nurse include as foot care for this client?
1. Cut toenails in a rounded shape and file.
2. Dry toes thoroughly.
3. Wash feet with water at a temperature of 90F to 98.6F.
4. Inspect feet thoroughly once a week. - Accurate answers 2. Dry toes thoroughly
Rationale 1: Toenails should be cut straight across, and nurses do not cut diabetic clients toenails. Only a
podiatrist should handle this task.
Rationale 2: Toes should be dried thoroughly after being washed to impede fungal growth and
preventmaceration.
Rationale 3: The water to wash the feet should be 100F to 110F.
Rationale 4: Feet should be inspected each day, not once a week, for early detection of any problems.
client has the nursing diagnosis Risk for Impaired Skin Integrity related to immobility. Which nursing
intervention should be identified for this clients problem?
1. Encourage the client to eat at least 40% of meals.
2. Keep linens dry and wrinkle-free.
3. Restrict fluid intake.
4. Turn client every 3 hours. - Accurate answers 2. Keep linens dry and wrinkle free.
Rationale 1: For nutritional support to promote healthy tissue, clients should consume more than 40% of
their meals.
Rationale 2: Keeping linens dry and wrinkle-free will prevent pressure areas.
Rationale 3: Fluids should not be restricted unless some other physical condition dictates. The skin
should be kept hydrated.
Rationale 4: To relieve pressure, the client should be turned every 2 hours, not every 3.
