Basic Care and Comfort NCLEX

Extract:

Question 1 of 5

A client is to have an enema to reduce flatus. The enema tube should be inserted:

Correct Answer: A

Rationale: Enema tubing must be passed beyond the internal sphincter. Two inches is not far enough to pass the internal sphincter. Both 6 and 8 inches are too far and might cause trauma to the bowel.

Question 2 of 5

The client with a new colostomy asks how to deal with gas coming from the stoma. To respond to the client's concern, the nurse should ask the client to take which action? Select all that apply.

A. Describe the dietary intake, including types of foods. B. Include cruciferous vegetables in the diet daily. C. Decrease fluid intake to 1200 mL per 24 hours. D. Prick the colostomy stoma pouch with a pin. E. Limit intake of gas-producing carbonated sodas. F. In the bathroom, open the pouch clamp to release gas.

Correct Answer: A,E,F

Rationale: A: Assessing diet identifies gas-producing foods. E: Limiting carbonated drinks reduces gas. F: Releasing gas in a bathroom controls odor. B: Cruciferous vegetables increase gas. C: Reduced fluid risks dehydration. D: Pricking the pouch causes leaks and odor.

Question 3 of 5

The hospitalized client is at risk for thromboembolism. Which direction should the nurse include when teaching this client about wearing antiembolism hose stockings?

A. Wearing the hose is unnecessary if ambulating 10 times daily for 5 minutes at a time. B. When at home, apply the stockings in the morning before you stand to get out of bed. C. The hose can cause pain to underlying skin; request pain medication to help alleviate this. D. Cross your legs only while wearing these stockings; otherwise keep the legs uncrossed.

Correct Answer: B

Rationale: B: Applying stockings before standing maximizes compression and prevents edema. A: Stockings complement ambulation. C: Pain suggests circulation issues, not requiring pain medication. D: Crossing legs impedes circulation.

Question 4 of 5

A nurse is working in a pediatric clinic and a mother brings in her 13 month old child who has Down Syndrome. The mother reports, 'My child's muscles feel weak and he isn't moving well. My RN friend checked his reflexes and she said they are diminished.' Which of the following actions should the nurse take first?

A. Contact the physician immediately B. Have the patient go to X-ray for a c-spine work-up. C. Start an IV on the patient D. Position the child's neck in a neutral position

Correct Answer: D

Rationale: An atlanto-axial dislocation may have occurred, common in Down Syndrome. Positioning the child's neck in a neutral c-spine posture is the first step to prevent further injury, followed by contacting the doctor.

Question 5 of 5

Mr. H. is upset regarding being in the hospital for another day because he states it costs too much. The rights he is likely to demand include all of the following except:

A. the right to examine and question the bill B. the right to reasonable response to requests C. the right to refuse treatment D. the right to confidentiality

Correct Answer: D

Rationale: The client's concern about costs suggests he may demand to examine the bill, expect reasonable responses, or refuse treatment. Confidentiality, while a right, is unrelated to his stated financial concerns and is not suggested to be breached.

Basic Care and Comfort NCLEX | Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN