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NCLEX basic care and comfort questions with correct answer1.
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NCLEX basic care and comfort questions with correct answer1.
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NCLEX basic care and comfort questions with correctanswers
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
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