NCLEX-PN
Basic Care and Comfort NCLEX Questions Questions
Extract:
Question 1 of 5
A client is on a clear liquid diet. She drinks half of a 12-ounce juice, 4 ounces of soup, and has a 6-ounce JELLO0. How many milliliters of fluid did the patient ingest?
Correct Answer: B
Rationale: 1 ounce = 30 ml, so Juice, 6 ounces (half of 12 oz) × 30 = 180 ml (Remember that oz is an abbreviation for ounces.) Soup, 4 ounces × 30 = 120 ml JELL-OB, 6 ounces × 30 = 180 ml 180 + 120 + 180 = 480 ml Note that gelatin, ice cream, and other things that are liquid at room temperature are counted as fluids.
Question 2 of 5
Client room environments should include:
Correct Answer: B
Rationale: Preparing a client's room environment should include making the client's bed, ensuring comfort and safety at all times, keeping the area free of clutter, and keeping the client's hygiene articles nearby. All procedures should be explained before they are performed, and the client should assist with personal arrangement of articles.
Question 3 of 5
A nurse is caring for a patient in the step down unit. The patient has signs of increased intracranial pressure. Which of the following is not a sign of increased intracranial pressure?
Correct Answer: B
Rationale: Unilateral pupil changes indicate changes in ICP.
Question 4 of 5
A client is on a clear liquid diet. She drinks half of a 12-ounce juice, 4 ounces of soup, and has a 6-ounce JELLO0. How many milliliters of fluid did the patient ingest?
Correct Answer: B
Rationale: 1 ounce = 30 ml, so Juice, 6 ounces (half of 12 oz) × 30 = 180 ml (Remember that oz is an abbreviation for ounces.) Soup, 4 ounces × 30 = 120 ml JELL-OB, 6 ounces × 30 = 180 ml 180 + 120 + 180 = 480 ml Note that gelatin, ice cream, and other things that are liquid at room temperature are counted as fluids.
Question 5 of 5
A client with major head trauma is receiving bolus enteral feeding. The most important nursing order for this client is:
Correct Answer: A
Rationale: Measuring intake and output assesses fluid balance, critical in enteral feeding to prevent dehydration or fluid overload due to hyperosmotic feedings.