NCLEX Basic Care and Comfort

Extract:

Question 1 of 5

Following the change of shift report, the nurse should analyze the information and set priorities accordingly. When the plan has been formulated, at what point during the shift can or should the nurse's plan be altered or modified?

Correct Answer: C

Rationale: The nurse should modify the care plan whenever the client's needs change to ensure responsive and effective care, rather than at fixed times or only after completing tasks.

Question 2 of 5

The nurse is using Cognitive-Behavioral methods of pain control and knows that these methods can be expected to do all the following except:

A. completely relieve all pain. B. provide benefit by restoring the client's sense of self-control. C. help the client to control symptoms. D. help the client actively participate in his or her own care.

Correct Answer: A

Rationale: These interventions (strategies) help the client in all areas of client well-being. Focusing on perception and thought, cognitive techniques are designed to influence how one interprets events and bodily sensations.

Question 3 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?

A. inability to turn, cough, and breathe deeply B. inability to communicate pain C. inability to ambulate freely D. inability to use a bedside commode

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 4 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 5 of 5

The nurse is observing the UAP prepare a shower for the client who requires assistance with ambulation and hygiene. Which action(s) by the UAP indicate understanding of the procedure? Select all that apply.

A. Sets the water temperature at 100Â° to 105Â° F (37Â° to 40Â° C). B. Locks the door to provide the client with privacy. C. Uses a chair for the client to sit on in the shower. D. Ensures a nonskid surface is in the shower. E. Helps to wash areas the client cannot reach.

Correct Answer: C,D,E

Rationale: C: A shower chair prevents falls for a client with ambulation issues. D: A nonskid surface enhances safety. E: Assisting with hard-to-reach areas supports hygiene. A: Water should be 110Â°-115Â°F for comfort. B: Locking the door is unsafe for a client needing assistance.

NCLEX Basic Care and Comfort | Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN