NCLEX-PN
NCLEX Basic Care and Comfort Questions
Extract:
Question 1 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.
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 2 of 5
The nurse is caring for the 11-month-old infant with bronchopulmonary dysplasia. The infant has 30% supplemental oxygen provided via a tracheostomy. Which action should the nurse take when the infant has a decline in oxygen saturation from 96% to 87% and appears anxious and restless?
Correct Answer: C
Rationale: C: Suctioning clears potential airway obstructions causing desaturation. A: ABGs are secondary if suctioning resolves distress. B: Increasing oxygen is ineffective with an occluded airway. D: Medication doesn't address airway issues.
Question 3 of 5
The client has dentures, including both upper and lower plates. Which technique should the nurse use to correctly perform oral hygiene for this client?
Correct Answer: C
Rationale: C: Grasping the upper plate and moving it breaks the suction that holds the plate on the roof of the client's mouth. A: Removing denture plates is a clean procedure, and sterile gloves are not necessary. B: Removing the denture plates with a foam swab to pry the plate could injure the client. D: Dentures must be removed to properly clean the client's mouth and the dentures.
Question 4 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 5 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.