Basic Care and Comfort Actual Exam Questions and CORRECT Answers
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Course
Basic Care and Comfort
Institution
Basic Care And Comfort
Basic Care and Comfort Actual Exam
Questions and CORRECT Answers
A nurse working in an orthopedic unit is caring for four clients. Which of the following
clients is at greatest risk for skin breakdown? - CORRECT ANSWER- An older adult
client who has a hip fracture and is in Buck's traction.
...
Basic Care and Comfort Actual Exam
Questions and CORRECT Answers
A nurse working in an orthopedic unit is caring for four clients. Which of the following
clients is at greatest risk for skin breakdown? - CORRECT ANSWER✔✔- An older adult
client who has a hip fracture and is in Buck's traction.
-Due to the aging process (decreased muscle mass, thin and fragile skin), and the limitation of
movement of this client, this client is at the greatest risk for skin breakdown.
A nurse is preparing to remove an NG tube from a client. Which of the following should be
the nurse's priority action? - CORRECT ANSWER✔✔- Verify provider order to discontinue
the tube.
-Discontinuing a NG tube requires a provider order. Therefore, confirmation of an order
would be a priority before removal of the tube. Nasogastric tubes can be used to provide
enteral nutrition, to administer medication, and to provide gastric decompression.
A nurse is teaching a client how to follow a low-purine diet as prescribed by the provider for
the management of gout. Which of the following statements indicates the client understands
the teaching? - CORRECT ANSWER✔✔- "Liver must be eliminated from my diet."
-The nurse should encourage the client who has gout to avoid organ meats, such as liver due
to high levels of purine.
-Patients who have gout should include fruit servings as part of a healthy diet
A nurse is caring for a client who is prescribed an infusion of 5% dextrose in water. Which of
the following is the amount of dextrose in this solution? - CORRECT ANSWER✔✔- 5 g/100
mL
-A solution of 5% dextrose in water contains 5 grams of dextrose per 100 mL.
A nurse is providing oral care for an immobilized client. Which of the following interventions
should the nurse take? - CORRECT ANSWER✔✔- Position the client on one side before
starting oral care.
-This is the appropriate action. Placing the client on one side encourages fluids to run out of
the client's mouth, lessening the risk of aspiration and choking.
,A nurse is caring for a client who has type 1 diabetes mellitus. Which of the following should
the nurse recommend to the client as an appropriate sweetener? - CORRECT ANSWER✔✔-
Nonnutritive sugar substitute
-Clients who have type 1 diabetes mellitus should limit carbohydrate intake. Nonnutritive
sugar substitutes allow the client to sweeten the taste of foods without increasing
carbohydrate intake.
A nurse is caring for a client who requires cold applications with an ice bag to reduce the
swelling and pain of an ankle injury. Which of the following is an appropriate nursing
intervention? - CORRECT ANSWER✔✔- Apply the bag for 30 min at a time.
-The nurse should leave the bag in place for 30 min, but should check the client's skin after
15 min to make sure there are no unexpected effects.
-Wait 1 hr after removing the ice to reapply
A nurse auscultates a client's bowel sounds. Which of the following actions by the nurse
would require intervention by a charge nurse? - CORRECT ANSWER✔✔- Palpates the
abdomen prior to performing auscultation.
-Bowel sounds should be auscultated prior to palpation because manipulation of the abdomen
can alter the frequency and intensity of bowel sounds. Bowel sounds should be auscultated in
all four quadrants with the warm diaphragm of a stethoscope.
-If an NG tube is present, it should be clamped during auscultation to prevent the sound of
suction being mistaken for bowel sounds.
-Bowel sounds are best auscultated between meals
A nurse is reinforcing teaching about nutritional considerations with the parents of a toddler.
Which of the following statements by the parents indicates understanding of the teaching? -
CORRECT ANSWER✔✔- "The quality of food I provide him is more important than the
quantity."
-Toddlers are very picky eaters and usually eat only one or two adequate meals each day.
Therefore, it is essential that the meals are balanced with essential nutrients. The nutritious
quality of the food is much more important than the quantity. Toddlers generally prefer finger
foods because of increasing autonomy. Eating habits established in the first 2 to 3 years of
life tend to have lasting effects on subsequent years.
A nurse is caring for a client who has been on strict bed rest for 1 week. Which of the
following findings indicates client readiness to ambulate? - CORRECT ANSWER✔✔-
Performs active range of motion exercise to all extremities
, -During periods of immobility, it is important to have the client perform range of motion
(ROM) exercise to reduce the hazards of immobility (e.g., contractures, loss of muscle mass,
and thrombosis). A client who is weak may be able to perform only passive ROM exercises,
during which the nurse assists the client by supporting the extremities during movement.
During active ROM, the client is doing the movement with little to no assistance. The client
may be able to actively move some extremities and joints and require assistance with others.
This is a collaborative effort with physical therapy to safely ensure that the client restores
mobility.
A nurse is caring for a client following the surgical placement of a colostomy. Which of the
following statements indicates the client understands the dietary teaching? - CORRECT
ANSWER✔✔- "Eating yogurt can help decrease the amount of gas that I have."
-The client who has a colostomy can include yogurt into his diet to help reduce odors and
intestinal gas.
A nurse is caring for a client following a left hip arthroplasty. Which of the following should
the nurse implement to prevent dislocation? - CORRECT ANSWER✔✔- Maintain foam
wedge between legs.
-Because the muscle surrounding the hip joint has been cut to expose and replace the diseased
joint, clients are at risk for hip dislocation. Proper body alignment after total hip arthroplasty
includes keeping the affected leg slightly abducted. A major complication of total hip
arthroplasty is subluxation (partial dislocation) or total dislocation. In some facilities,
abduction devices such as foam wedges and pillows are placed between legs. Adduction of
the hip should be avoided to prevent dislocation.
- CORRECT ANSWER✔✔- A major complication of total hip replacement is subluxation
(partial dislocation) or total dislocation. In addition to preventing adduction, the client should
avoid flexing the hips more than 90°, not 60°. The nurse should use diagrams or demonstrate
correct positioning to help reinforce this information prior to the surgical procedure.
A nurse provides teaching to a client who is being fitted for a prosthetic leg. Which of the
following statements indicate to the nurse a need for further instruction? - CORRECT
ANSWER✔✔- "The prosthesis fitting will occur at the time the staples are removed."
-This is a false or untrue statement and indicates a need for further instruction. The staples are
removed before the shrinking and shaping of the residual leg is complete. The prosthesis
would not fit once this process is complete.
A nurse is preparing a teaching plan for a client who has neutropenia as a result of radiation
therapy for the treatment of lung cancer. Which of the following should the nurse plan to
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