NCLEX Basic Care and Comfort

Extract:

Question 1 of 5

A wrong committed by one person against another (or against the property of another) that might result in a civil trial is:

Correct Answer: A

Rationale:
Torts are wrongs committed by one person against another person (or against the property of another), which might result in civil trials. A crime is also defined as a wrong against a person or their property but is considered to be against the public as well. Misdemeanors are crimes that are commonly punishable with fines or imprisonment for less than one year, with both or with parole. A felony is a serious crime punishable by imprisonment in a State or Federal penitentiary for more than one year.

Question 2 of 5

A safety measure to implement when transferring a client with hemiparesis from a bed to a wheelchair is:

A. standing the client and walking him or her to the wheelchair. B. moving the wheelchair close to client's bed and standing and pivoting the client on his unaffected extremity to the wheelchair. C. moving the wheelchair close to client's bed and standing and pivoting the client on his affected extremity to the wheelchair. D. having the client stand and push his body to the wheelchair.

Correct Answer: B

Rationale: Moving the wheelchair close to client's bed and having him stand and pivot on his unaffected extremity to the wheelchair is safer because it provides support with the unaffected limb.

Question 3 of 5

The nurse is caring for the client with a stage III pressure ulcer to the right heel. Which actions should the nurse plan? Select all that apply.

A. Encourage foods high in vitamin C such as orange juice B. Premedicate with analgesics prior to dressing changes C. Monitor pedal pulses and capillary refill of affected extremity D. Use hydrogen peroxide for cleaning of the ulcer wound E. Turn and reposition the client every 1 to 2 hours F. Elevate the extremity on pillows, keeping the heel off the pillow

Correct Answer: A,B,C,E,F

Rationale: A: Vitamin C aids wound healing. B: Analgesics improve comfort. C: Pulse checks detect vascular issues. E: Repositioning prevents further breakdown. F: Elevation and offloading reduce pressure. D: Hydrogen peroxide harms tissue.

Question 4 of 5

To remove a client's gown when she has an intravenous line, the nurse should:

A. temporarily disconnect the intravenous tubing at a point close to the client and thread it through the gown. B. cut the gown with scissors. C. thread the bag and tubing through the gown sleeve, keeping the line intact. D. temporarily disconnect the tubing from the intravenous container and thread it through the gown.

Correct Answer: C

Rationale: Threading the bag and tubing through the gown sleeve keeps the system intact. Opening an intravenous line causes a break in a sterile system and introduces the potential for infection. Cutting a gown off is not an alternative except in an emergency. IV gowns, which open along sleeves, are widely available.

Question 5 of 5

A nurse is assigned to do pre-operative teaching on a blind patient who is scheduled for surgery the following morning. What teaching strategy would best fit the situation?

A. Verbal teaching in short sessions throughout the day. B. Pre-operative booklet on the surgery in Braille. C. Provide a tape for the client. D. Have the blind patient's family member instruct the patient.

Correct Answer: A

Rationale: Information is smaller amounts is easier to retain. Teaching the day before the procedure is best accomplished in a one on one format.

NCLEX Basic Care and Comfort | Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN