NCLEX-PN
Basic Care and Comfort NCLEX Questions
Extract:
Question 1 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?
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 2 of 5
Perineal care to a female client by the nurse can be performed:
Correct Answer: C
Rationale: Perineal care requires gloves and washing from front to back to prevent bacterial contamination of the urethra, ensuring infection control.
Question 3 of 5
The LPN is assisting the client with an NG tube with activities of daily living. Which of these statements would indicate need for teaching reinforcement?
Correct Answer: A
Rationale: Even when an NG tube is in place, the client still should brush his or her teeth twice daily. Good oral hygiene reduces the risk of introducing bacteria that may cause an infection.
Question 4 of 5
Using the FLACC pain scale, how should the LPN document pain for a non-verbal client with these findings: 1.Face-occasional grimacing 2.Legs-relaxed 3.Activity-Squirming 4.Cry-moans and whimpers 5.Consolability-distractible
Correct Answer: B
Rationale: The points add up like this: Face-1 Legs-0 Activity-1 Cry-1 Consolability-1
Total pain score-4
Question 5 of 5
An LPN is caring for a primarily bedridden client. Which finding should be of least concern?
Correct Answer: D
Rationale: Capillary refill time of longer than three seconds may indicate inadequate blood flow; capillary refill time of 2-3 seconds is a normal finding. Swollen feet, brown discoloration, and leg pain may be signs of venous insufficiency to the lower extremities.