NCLEX Basic Care and Comfort

Extract:

Question 1 of 5

An 80-year-old aphasic CVA client had abdominal surgery 2 days ago. Which of the following puts this client at the highest risk for inadequate pain management?

Correct Answer: B

Rationale: The client cannot speak to alert the nurse to his pain state. The nurse needs to provide alternate methods of communication with the client.

Question 2 of 5

Which of the following statements indicates that the nurse understands how to promote rest and sleep for the client?

A. If you would prefer to not be disturbed, we can postpone all vital signs and assessments until tomorrow morning. B. With your physical therapy appointments, you cannot nap more during the day even if your sleep is often interrupted at nighttime. C. I can try to incorporate any sleep rituals or an ideal bedtime into your routine. D. We cannot group together medications, assessments, and other interventions so you may have multiple interruptions at night.

Correct Answer: C

Rationale:
To promote rest and sleep, the nurse should try to incorporate any client preferences into the evening routine.

Question 3 of 5

Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes a serosanguious drainage on the dressing. The most appropriate intervention is to:

A. notify the physician of the drainage. B. change the dressing. C. reinforce the dressing. D. apply an abdominal binder.

Correct Answer: C

Rationale: Serosanguious drainage is expected at this time. The dressing should be reinforced. Changing a new postop dressing increases the risk of infection. An abdominal binder interferes with visualization of the dressing.

Question 4 of 5

To ensure proper immobilization and increase client comfort when using a rigid splint:

A. place the client on a stretcher before splinting B. place the client on a long spine board before splinting C. pad the spaces between the body part and the splint D. ensure that the splint conforms to the body curves

Correct Answer: C

Rationale: Padding spaces in a rigid splint prevents pressure points, enhancing comfort and ensuring effective immobilization.

Question 5 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.

NCLEX Basic Care and Comfort | Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN