Basic Care and Comfort NCLEX

Extract:

Question 1 of 5

The client with an indwelling urinary catheter requires discharge teaching. Which interventions should the nurse include in the teaching plan? Select all that apply.

Correct Answer: B,C,E

Rationale: B: Daily cleansing with soap and water prevents infection. C: Securing the catheter reduces trauma. E: Hand hygiene minimizes infection risk. A: Monthly changes are recommended unless blockage occurs. D: Showering is safe if the client's condition allows.

Question 2 of 5

A spinal change occurring with pregnancy that alters mobility is:

A. scoliosis. B. kyphosis. C. lordosis. D. ankylosing spondylitis.

Correct Answer: C

Rationale: The spinal change occurring with pregnancy is lordosis. This occurs due to the weight of the enlarging uterus and the affect of gravity.

Question 3 of 5

The nurse needs nasotracheal suctioning. The nurse explains the procedure to the client and performs hand hygiene. Prioritize the nurse's remaining actions to perform the nasotracheal suctioning by placing each step in the correct order.

Order the Items

Source Container

Prepare suction supplies and equipment and pour sterile saline into a sterile container.

Place finger over suction control port of catheter and suction intermittently while withdrawing the catheter.

Put on sterile gloves.

Lubricate the catheter with sterile saline, insert into naris, and advance into pharynx.

When the client inhales, advance the catheter into the trachea.

Pick up suction catheter with the dominant hand and attach it to connection tubing; avoid contamination of the glove on the dominant hand.

Place tip into sterile saline container while applying suction to clear secretions from the tubing

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

Rationale: A: Preparing supplies comes first. C: Sterile gloves maintain asepsis. F: Handling catheter keeps dominant hand sterile. D: Lubrication aids insertion. E: Advancing during inhalation ensures tracheal placement. B: Intermittent suction prevents trauma. G: Clearing tubing prevents reinsertion of secretions.

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

A. 5 B. 4 C. 3 D. 8

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

The client residing in a nursing home has bilateral weak handgrips and visual and hearing deficits. Which interventions should the nurse implement when the client is eating a meal? Select all that apply.

A. Ask the client's permission to open containers and cut up meats on the food tray. B. Obtain special easy-to-hold, built-up silverware for the client to use when eating. C. Observe the client, but avoid providing assistance even if the client is frustrated. D. Help feed the client if the client is eating too slowly so food does not get too cold. E. Ensure that the client wears eyeglasses and hearing aids before starting to eat.

Correct Answer: A,B,E

Rationale: A: Asking permission promotes autonomy. B: Built-up silverware aids weak grips. E: Sensory aids enhance independence. C: Assistance reduces frustration. D: Feeding discourages independence.

Basic Care and Comfort NCLEX | Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN