NCLEX-RN
RN Nursing Basic Care and Comfort Questions
Question 1 of 3
The nurse is caring for a group of clients in a medical/surgical unit. Which client does the nurse understand to be at highest risk for developing decubitus ulcers?
Correct Answer: C
Rationale: The obese client in a wheelchair (
C) has prolonged pressure and reduced mobility, increasing decubitus ulcer risk. Arm fracture (
A), traction (
B), and ambulatory client (
D) have lower risk.
Question 2 of 3
The nurse is assessing a six-month-old infant at the clinic. When the nurse strokes from the heel of the foot upward toward the ball, the infant exhibits no movement. Which action is the priority for the nurse?
Correct Answer: B
Rationale: No movement in response to the Babinski reflex (fanning toes) at six months suggests neurological abnormality, warranting a neurology consult (
B). Other actions (A, C,
D) are less urgent.
Question 3 of 3
The nurse is caring for a client with fluid overload who is on strict I's and O's. The nurse understands that which is the best way to ensure accurate I's and O's?
Correct Answer: A
Rationale: Accurate I's and O's require nurse measurement of all fluids, including IVs and oral intake, and urine output, typically using graduated containers. None of the options fully ensure accuracy, as they rely on client reporting or incomplete measures.
Question 4 of 3
Correct Answer:
Rationale:
Question 5 of 3
Correct Answer:
Rationale: