NCLEX-PN
NCLEX Basic Care and Comfort Questions
Extract:
Question 1 of 5
The client voided 300 mL after having an indwelling urinary catheter removed six hours ago. A bladder scan immediately after the void showed that the client has a postvoid residual (PVR) volume of 250 mL. What should the nurse conclude from this finding?
Correct Answer: D
Rationale: D: A PVR of 250 mL indicates incomplete bladder emptying, as normal PVR is less than 50 mL. A: High PVR is not expected. B: PVR doesn't quantify bladder function percentage. C: No evidence suggests timing was incorrect.
Question 2 of 5
The postoperative male client has been unable to urinate into the urinal while lying in bed. Which interventions are appropriate to promote voiding for this client who is to be discharged home within a few hours? Select all that apply.
Correct Answer: B,C,D,E
Rationale: B: Standing mimics normal voiding position. C: Pain relief aids relaxation for voiding. D: Running water stimulates the voiding reflex. E: Guided imagery promotes relaxation. A: Condom catheters manage incontinence, not promote voiding.
Question 3 of 5
The client uses a walker to ambulate with partial weight-bearing after foot surgery. What should the nurse observe when this client is using the walker correctly?
Correct Answer: A
Rationale: A: Elbows at 30 degrees indicate proper walker height. B: Bending over risks poor posture and falls. C: Lifting the walker prevents partial weight-bearing. D: Four-wheeled walkers are unsuitable for partial weight-bearing.
Question 4 of 5
The nurse applies a warm, moist compress to the site where an IV solution has infiltrated. Which response is correct when the client asks the purpose of the compress?
Correct Answer: D
Rationale: D: Warm compresses increase blood flow, promoting healing. A: Cold causes numbness. B: Heat increases metabolic needs. C: Cold reduces histamine release.
Question 5 of 5
The dietitian prescribes a 24-hour calorie count for the malnourished hospitalized client. Which action should be taken by the nurse?
Correct Answer: C
Rationale: C: Recording food intake ensures accurate calorie counts. A: Recall is unreliable. B: Clients don't calculate calories in hospital. D: Food groups don't provide calorie data.