NCLEX-PN
Basic Care and Comfort NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse learns at shift report that the immobile client has bilateral foot drop. Which finding during the nurse's assessment supports the presence of foot drop?
Correct Answer: B
Rationale: B: Inability to hold feet perpendicular indicates foot drop. A: This describes a Babinski sign. C: Foot drop involves persistent plantar flexion, not inability to plantar flex. D: Foot drop prevents dorsiflexion.
Question 2 of 5
A nurse is caring for a patient in the step down unit. The patient has signs of increased intracranial pressure. Which of the following is not a sign of increased intracranial pressure?
Correct Answer: B
Rationale: Unilateral pupil changes indicate changes in ICP.
Question 3 of 5
As part of the teaching plan for a client with type I diabetes mellitus, the nurse should include that carbohydrate needs might increase when:
Correct Answer: D
Rationale: Active exercise increases insulin sensitivity, thus lowering blood glucose levels. Additional carbohydrates might be needed to balance the usual insulin dose. All of the other choices increase blood glucose levels.
Question 4 of 5
The client who has bilateral hand burns reports wearing soft contact lenses that need to be removed. Which action(s) are important for the nurse to include in this procedure? Select all that apply.
Correct Answer: A,C,E
Rationale: A: Hand hygiene and gloves prevent infection. C: Normal saline keeps lenses moist if no lens solution is available. E: Looking up aids safe lens removal. B: Pinching over the pupil risks corneal abrasion. D: Irrigation could damage or lose the lens.
Question 5 of 5
For a client requiring total oral care, it is important for the nurse to:
Correct Answer: C
Rationale: Assemble all equipment first; place the client in a side-lying position so that fluid can easily flow out or pool in the side of the mouth for suctioning (to prevent aspiration); and then place a towel under the client's chin and a curved basin against the chin. Gloves should be worn.