Basic Care and Comfort NCLEX

Extract:

Question 1 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

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 2 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.

A. Plan to change the urinary catheter once a week. B. Cleanse the perineal area daily with soap and water. C. Secure the catheter tubing to the thigh with tape. D. Avoid showering while the catheter is in place. E. Perform hand hygiene before and after catheter care.

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 3 of 5

The experienced nurse observes the student nurse caring for the client with the wet plaster cast illustrated. Which conclusion by the experienced nurse is correct?

A. The student should not be touching the plaster cast because it is wet. B. The student should be using a pillow to lift the client's casted extremity. C. The student is correctly handling a wet plaster cast with the palms. D. The student should be using fingers and not the palms to handle the cast.

Correct Answer: C

Rationale: C: Using palms prevents indentations in wet casts. A: Wet casts can be touched to reposition. B: Pillows limit inspection of the cast underside. D: Fingers cause pressure points.

Question 4 of 5

A nurse is working in a pediatric clinic and a mother brings in her 13 month old child who has Down Syndrome. The mother reports, 'My child's muscles feel weak and he isn't moving well. My RN friend checked his reflexes and she said they are diminished.' Which of the following actions should the nurse take first?

A. Contact the physician immediately B. Have the patient go to X-ray for a c-spine work-up. C. Start an IV on the patient D. Position the child's neck in a neutral position

Correct Answer: D

Rationale: An atlanto-axial dislocation may have occurred, common in Down Syndrome. Positioning the child's neck in a neutral c-spine posture is the first step to prevent further injury, followed by contacting the doctor.

Question 5 of 5

Ms. Petty is having difficulty falling asleep. Which of the following measures promote sleep?

A. exercising vigorously for 20 minutes each night beginning at 9:30 p.m. B. taking a cool shower and drinking a hot cup of tea C. watching TV nightly until midnight D. getting a back rub and drinking a glass of warm milk

Correct Answer: D

Rationale: A back rub and warm milk promote relaxation and sleep. Vigorous exercise, cool showers, hot tea, and late TV watching are stimulating and disrupt sleep.

Basic Care and Comfort NCLEX | Nurselytic

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NCLEX-PN

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