Basic Care and Comfort NCLEX RN Questions

Basic Care and Comfort NCLEX RN Questions Related

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The nurse is caring for a client who is sedated and on the ventilator in ICU. The family expresses concern about controlling the client's pain when he cannot speak. The nurse explains that assessing pain in a nonverbal client involves watching for which of the following signs? Select all that apply.

  • A. grabbing at the bed rails
  • B. biting the ventilator tubing
  • C. facial grimacing
  • D. stiffness or rigidity of the body
  • E. decreased urinary output
  • F. increased blood pressure and heart rate as shown on the cardiac monitor
Correct Answer: B,C,D,F

Rationale: Biting tubing (B), grimacing (C), stiffness/rigidity (D), and elevated BP/heart rate (F) indicate pain in nonverbal clients. Grabbing rails (A) is less specific, and urinary output (E) is unrelated.

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The nurse is caring for a client who has a nasogastric tube for medication administration and tube feedings. How should the nurse care for the tube during her shift? Select all that apply.

  • A. flush tube every 4 hours with hot water to maintain patency
  • B. allow the feeding and tubing to hang until empty, up to 48 hours
  • C. maintain the head of bed in a high-Fowler's position during feedings
  • D. check residuals and replace them unless the amount is greater than 300 mL
  • E. check under the adhesive tape on the nose daily to assess for skin breakdown
  • F. assess the bowel sounds before feeding, and feed at half the rate if bowel sounds are absent
Correct Answer: C,E

Rationale: High-Fowler's position (C) prevents aspiration, and checking for skin breakdown (E) prevents injury. Hot water (A) is unsafe, feedings shouldn't hang >4-8 hours (B), residuals >200-250 mL typically require holding (D), and absent bowel sounds contraindicate feeding (F).

The nurse is assisting the health care provider performing a liver biopsy on a client. How should the nurse position this client? Select all that apply.

  • A. position the client supine with the left upper abdomen exposed
  • B. position the client supine with the right upper abdomen exposed
  • C. position the client in a low Fowler's with the right upper abdomen exposed
  • D. raise the client's right arm and extend it behind the head, over the left shoulder
  • E. raise the client's right arm and extend it across the front of the chest touching the left shoulder
Correct Answer: B,D

Rationale: For a liver biopsy, the client is positioned supine with the right upper abdomen exposed (liver location) and the right arm raised behind the head to expand the rib cage and improve access to the liver.

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