Basic Care and Comfort 280 questions NCLEX-RN QBANK. WITH 100% CORRECT AMD VERIFIED ANSWERS. LATEST 2024 UPDATE, GUARANTEED A+ SCORE

conductive hearing loss? A The client hears the sound vibrate from the top of the head in the affected ear. Correct Answer (Blank) B The client hears the sound by air conduction longer than feeling bone conduction. C The client feels the bone conduction longer than hearing the sound conduction. D The client pushes on the tragus while repeating back what is whispered. Question Explanation Rationale: For the Weber test, the tuning fork is placed on the bridge of the forehead, nose, or teeth. In a normal test, the sound is heard equally in both ears. With unilateral conductive loss, sound is heard in the affected ear. With unilateral sensorineural loss, sound is heard in the normal or better-hearing side. In a Rinne test, the tuning fork is placed on the mastoid bone behind the ear until the client can no longer feel the vibration. The fork is then moved beside the ear. In a normal test, air conduction is greater than bone conduction. The whisper test has the client repeat what is heard while pushing on the tragus. Concepts tested NCLEX: Basic Care and Comfort The nurse is reviewing written education with a client. The nurse notes the client squinting and moving the document close to their eyes. What assessment tool would be used to collect additional information about this patient's problem? A Snellen chart B Jaeger test Correct Answer (Blank) C Confrontation test D Ishihara cards Question Explanation Rationale: The Snellen chart is used to assess far vision; the Jaeger test is used for near vision. Confrontation tests assess visual field and peripheral field deficits. Ishihara cards assess for the ability to differentiate color. Concepts tested NCLEX: Basic Care and Comfort aphasia? A The client is unable to comprehend what others are saying. B The client speaks in nonsensical sentences. C The client has difficulty forming words. Correct Answer (Blank) D The client demonstrates the inability to understand written words. Question Explanation Rationale: Patients with a stroke in the brain’s left hemisphere are more likely to have language deficits. Damage to the Wernicke area may lead to difficulty understanding verbal communication, called receptive aphasia. Damage to the Broca area causes problems with speaking or finding words, called expressive aphasia. The client with Broca’s aphasia has slow speech, difficulty in choosing words, and difficulty forming words. This leads to frustration as the client’s comprehension is intact. Wernicke’s aphasia is a loss of comprehension. Fluency remains but is nonsensical. Anomic aphasia leads to the inability to identify written words. Concepts tested NCLEX: Basic Care and Comfort Question 4 The nurse is assessing the client with a hearing deficit for pre-existing knowledge of hearing aid care. Which of the following statements by the client demonstrates correct care? A “I clean my hearing aids with a disinfectant cleanser weekly.” B “I open the battery door at night.” Correct Answer (Blank) C “I use a paper clip to clean the microphone port.” D “A whistling sound means I need to have my hearing aid checked.” Question Explanation Rationale: If the patient uses a hearing aid, check the batteries routinely and clean the earpieces or ear mold daily with mild soap and water. A whistling sound that is audible when the hearing aid is held in the hand with the power on and the volume high indicates that the battery is functioning properly. The microphone port should be cleaned with a hearing aid brush and pick. The shell and molds of the hearing aid should be cleaned with a chemical-free damp cloth. Concepts tested NCLEX: Basic Care and Comfort actions by the client is correct? A The client applies a stump sock over the residual limb. Correct Answer (Blank) B The client lubricates the prosthetic knee joint. C The client pads all areas of the socket that irritate the skin. D The client washes the liner weekly. Question Explanation Rationale: A stump sock is designed to redistribute pressure and wick moisture away from the skin. Prosthetics require no maintenance from the wearer outside of cleaning. Adjustments to the socket to prevent injury should be done by a therapist, prosthetist, or provider. Liners are washed and changed daily to prevent infection. Concepts tested NCLEX: Basic Care and Comfort The nurse is assessing a client with left-sided weakness while using a cane for ambulation. Which observation by the nurse would indicate correct use of the cane? A The client holds the cane in the left hand. B The client advances the weaker leg along with the cane. C The client advances the stronger leg with the cane. D The client holds the cane in the right hand. Correct Answer (Blank) Question Explanation Rationale: When walking with a cane, a client should hold the cane in the hand opposite the side that needs support. The patient stands with weight evenly distributed between the feet and the cane. The cane is held on the client’s stronger side and is advanced one small stride ahead. Supporting weight on the stronger leg and the cane, the patient advances the weaker foot forward, parallel with the cane. Then, supporting the weight on the weaker leg and the cane, the client brings the stronger leg forward to finish the step. Concepts tested NCLEX: Basic Care and Comfort The nurse is caring for a client experiencing left-sided homonymous hemianopsia after a cerebrovascular accident. The client has been leaving the left side of the meal plate untouched. Which of the following interventions should be implemented to improve intake? A Assist the client by feeding them the remaining food. B Provide the client with modified utensils for the left limb. C Encourage the client to perform visual scanning of the environment. Correct Answer (Blank) D Move all food into the functioning visual field. Question Explanation Rationale: Homonymous hemianopsia is a condition in which a person sees only one side ― right or left ― of the visual field of each eye. The condition results from a problem in brain function rather than a disorder of the eyes themselves. The most common cause is a stroke. Clients may bump into or fail to notice objects, including food on a plate. This is a problem with vision and not will weakness or paralysis, therefore the client does not need assistance being fed. Treatment includes training the client to move the eyes purposefully and move the head and eyes to the affected side. This is known as visually scanning the environment. Moving all food to the unaffected side does not promote independence/autonomy. Concepts tested NCLEX: Basic Care and Comfort The nurse is discussing the plan of care with an older adult client who wears hearing aids. The nurse notes the client leaning forward and asks the nurse to repeat the noise. Which action should the nurse take to assist the client? A Provide written materials for any message that cannot be heard B Decrease background noise Correct Answer (Blank) C Check hearing aids for function D Position self so that lips can be seen by the client Question Explanation Rationale: The priority action here is to reduce background noise, which is extremely distracting to a client with hearing aids. The client should be able to see the lips of the speaker, facial expressions, and hand movements. Hearing aids, if applicable, can be checked for dead batteries, etc. Finally, any message that cannot be verbally communicated can be written/typed. Concepts tested NCLEX: Basic Care and Comfort The nurses on a medical unit are participating in a quality improvement project to promote clients’ sleep and rest. Which of the following actions should be implemented? A Plan admissions to the unit during daylight hours B Silence the alarms in the nursing station C Schedule afternoon and nighttime “quiet time” hours Correct Answer (Blank) D Turn off all lights in the clients’ rooms at night Question Explanation Rationale: In this hospital, unfamiliar noises, such as people walking by or entering and leaving the room and the sounds of elevator doors, bring complaints from patients in health care facilities. Many health care facilities have made attempts to transform their patient care areas into quieter settings that facilitate rest and sleep. Attention to design features with a focus on eliminating environmental noise, providing patients with private rooms, and formal quiet times on units all are aimed at creating an environment that is conducive to good sleep. Alarms are a safety feature and should not be silenced. Admissions are nearly impossible to schedule as emergencies happen 24/7. Turning off lights may increase the risk of falls and injuries. Concepts tested NCLEX: Basic Care and Comfort The nurse is planning care for a client with a history of sleep-wake disturbances who reports a preferred bedtime at 10 pm. The nurse notes that the vital signs are scheduled for 11 pm. Which action would be appropriate for the nurse to take? A Take the client’s vital signs at 10 pm Correct Answer (Blank) B Ask the client to try to stay awake until 11 pm C Wake the client for 11 pm vital signs D Attempt to take the 11 pm vitals without waking the client Question Explanation Rationale: Whenever possible, provide care during periods when the patient is normally awake. When this is not feasible, avoid waking the patient during REM sleep, when rapid eye movements can be observed. Because a patient’s need for sleep is important, examine priorities for nursing care. For example, consider whether checking a vital sign or carrying out a particular nursing measure is more important than the patient’s sleep. It is safe to assess a client’s vital signs 1 hour before the scheduled time in this situation. Concepts tested NCLEX: Basic Care and Comfort appropriate? A Use toothpaste when brushing the dentures B Leave the dentures to air dry C Rinse the dentures in hot water D Line the sink with a towel when cleaning Correct Answer (Blank) Question Explanation Rationale: Dentures should be soaked in and brushed with a nonabrasive denture cleanser. Hot water may warp the plastic used to make the denture. Similarly, leaving them to air dry may cause warping. Lining the sink may prevent damage to the dentures if they are accidentally dropped. Concepts tested NCLEX: Basic Care and Comfort The nurse is caring for a client with myopia who wears eyeglasses. The client is on supplemental oxygen via nasal cannula. Which of the following actions is appropriate? A Encourage the client to keep the glasses wrapped in a napkin when not in use B Check the skin behind the ears for breakdown Correct Answer (Blank) C Place the glasses with the lenses down when the client removes them D Ask the family to take the glasses home for safe keeping Question Explanation Rationale: Eyeglasses are expensive items and should be protected from damage and loss. Wrapping the glasses in a napkin increases the likelihood that they will be thrown away. Lenses should be up to prevent scratching. Myopia is near-sightedness and therefore the client may need them to ambulate and perform activities of daily living (ADLs). Glasses, along with oxygen tubing, can contribute to skin breakdown, so the skin behind the ears should be assessed regularly. Concepts tested NCLEX: Basic Care and Comfort A The client uses the chair arms for support when rising from a seated position. B The client pushes the walker forward and then steps in between the back legs of the walker. C The client applies body weight to the walker for support. Correct Answer (Blank) D The client stands upright and looks forward when ambulating. Question Explanation Rationale: Walkers also are available with wheels on all four legs. Patients who require a larger base of support and do not rely on the walker to bear weight can use these. If full body weight is applied to this type of walker, it could roll away, resulting in a fall. Wheeled walkers are best for patients who need minimal weight bearing from the walker. All other actions are correct. Concepts tested NCLEX: Basic Care and Comfort actions requires intervention? A The client uses a toothbrush to clean the dentures. B The client uses regular toothpaste when brushing the dentures. Correct Answer (Blank) C The client stores the dentures in a covered container. D The client uses denture adhesive before placing them in the mouth. Question Explanation Rationale: Dentures should be cleaned using denture cleanser. Toothpaste may be too abrasive for the plastics in the dentures. All other practices are expected. Concepts tested NCLEX: Basic Care and Comfort A “I should put my weight on the pads under my arms.” B “I will keep my crutches close to my feet when walking.” C “I should be done with my crutches before I need to replace any parts.” D “I will come down the stairs with my good leg and crutches first.” Correct Answer (Blank) Question Explanation Rationale: The top of the crutches should be about 2 finger width below the armpit. Weight should be placed on the hand grips. Crutches should be routinely checked for wear and damage. Rubber crutch tips will need to be replaced when they are worn or cracked. Clients should be taught to descend the steps with the crutches and “good” leg first. Crutches should be at least 12 inches away from the feet to prevent falling. Concepts tested NCLEX: Basic Care and Comfort A “Loose and watery stools are expected with this type of ostomy.” B “Foods like applesauce and bananas can help with diarrhea.” Correct Answer (Blank) C “Wait to empty your pouch until it is 3/4 of the way full.” D “Reduce your fluid intake until the diarrhea subsides.” Question Explanation Rationale: Diarrhea may occasionally occur in a client with a sigmoid colostomy, however, the typical stool is firmer or more like a paste compared to a higher ostomy placement. Foods such as applesauce and bananas can help with diarrhea. Ostomy pouches should be emptied once they are half full to prevent leakage. Fluid intake should be encouraged to prevent dehydration. Concepts tested NCLEX: Basic Care and Comfort the nurse obtain first? A a stool specimen Correct Answer (Blank) B oral probiotics C a fecal managment system D oral antipyretic Question Explanation Rationale: Clostridium difficile is diagnosed through toxin testing of stool. Prompt diagnosis is required so treatment can begin. Probiotics, antipyretics, and a rectal tube, now known as a fecal management system, are acceptable interventions for antibiotic-associated diarrhea but are not the priority. Concepts tested NCLEX: Basic Care and Comfort The nurse is caring for a client with chronic pain who was prescribed oxycodone extended release for pain management. The client is concerned about developing constipation. Which response by the nurse is appropriate? A “Only take the medication when your pain is severe.” B “Increase your intake of dairy products.” C “We will ask your provider to order a daily stimulant laxative.” D “You can use a bulk forming laxative to help relieve your constipation.” Correct Answer (Blank) Question Explanation Rationale: Opioids are a common cause of medication-induced constipation and can result in significant distress for the patient. Increasing fluid and fiber in the diet are ways to prevent constipation. Psyllium, a form of insoluble fiber, is considered a bulk-forming laxative. Daily stimulant laxatives are avoided if possible due to significant side effects and rebound constipation. Dairy is constipating. Clients should be encouraged to increase their intake of fruits and vegetables. Extended-release opiates are scheduled and should not be taken in an as-needed fashion. Concepts tested Direct the solution to flow from the inner to outer canthus Correct Answer (Blank) B Don sterile gloves before beginning the procedure C Position the client on the left side D Ask the client to look to the right Question Explanation Rationale: Eye irrigation is performed to remove secretions or foreign bodies or to wash the eye after chemical injury. The head should be tilted slightly toward the affected side and the irrigant instills to flush from inner to outer canthus. Nonsterile gloves are used. The client should fix their gaze straight ahead. Concepts tested NCLEX: Basic Care and Comfort A Deflate the catheter balloon B Place the client in supine position C Purge the air from the tubing prior to connecting to the catheter Correct Answer (Blank) D Clamp the tubing above the access port Question Explanation Rationale: When providing continuous bladder irrigation, purge the air from the tubing to ensure that no air enters the system, similar to IV tubing. The client should be in semifowlers for CBI. The catheter balloon should not be deflated, or the catheter may dislodge. When performing intermittent irrigation, the catheter may be clamped below the access port.  YOUR SCORE 0% CORRECT 0 INCORRECT 0 BLANK 20 A nurse is caring for a client who has chronic venous insufficiency and is prescribed elastic compression stockings. Which action would be appropriate for the nurse to take? A Remove the stockings every two hours B Position the stockings from the client’s ankle to the thigh C Rub a small amount of lotion onto the client’s legs before applying stockings D Apply the elastic stockings before the client gets out of bed in the morning Correct Answer (Blank) Question Explanation Rationale: When applying elastic compression stockings, the nurse should apply the stockings before the client puts their feet in a dependent position (such as walking or sitting up with their feet dangling). This decreases the edema and eases the application of elastic stockings. An assessment of the area should take place at least once a shift. The nurse is assessing the color, temperature, and integrity of the skin. Elastic stockings are applied from the client’s toes to the thigh. Lotion should be avoided before applying compression stockings. Concepts tested NCLEX: Basic Care and Comfort Question 2 A nurse is caring for a client who has right-sided paralysis from a stroke. Which intervention should the nurse implement to prevent footdrop? A Place a sandbag to maintain right plantar flexion B Position soft pillows against the bottom of the feet C Apply a protective boot to the right ankle Correct Answer (Blank) D Splint the right lower extremity to maintain proper alignment Question Explanation Rationale: Footdrop occurs when the foot is permanently fixed in the plantar flexion position. To prevent foot drop, the nurse should apply a protective boot on the affected foot aligning the ankle. The nurse should avoid positioning the client with extended right plantar flexion. Pillows do not provide adequate support. The nurse should avoid splinting the entire extremity, which could limit the mobility of the extremity. Concepts tested NCLEX: Basic Care and Comfort A Place a transfer belt on the client B Position the bed at an appropriate height C Assist the client to a seated position D Obtain orthostatic vital signs Correct Answer (Blank) Question Explanation Rationale: A client who has been on bed rest is at risk for orthostatic blood pressure due to the decrease of venous return from muscle contraction. Before moving a client who has been on bed rest, the nurse should assess orthostatic blood pressure first. Then, the nurse will position the bed at an appropriate height, assist the client to a seated position, and then place the transfer belt on the client. Concepts tested NCLEX: Basic Care and Comfort A Place a folded blanket from the femur to the popliteal space Correct Answer (Blank) B Position a pillow under the shoulder with arm flexed C Lift lower extremities off the bed with folded blankets D Use pillows under the upper extremities with hands down Question Explanation Rationale: When placing the client in the supine position, the nurse should place a trochanter roll, a folded blanket, under the client’s femur extending to the popliteal place. The trochanter roll will prevent the external rotation of the hip. Positioning a pillow under the shoulder and lifting feet or upper extremities are used to decrease pressure on bony prominences but do not maintain proper alignment. Concepts tested NCLEX: Basic Care and Comfort The nurse is educating a client with newly diagnosed gout about dietary restrictions. Which statement made by the client would indicate to the nurse that further teaching is required? A “I will limit the amount of fruit juices I drink.” B “I should avoid carbonated beverages.” C “I will need to avoid alcohol.” D “I should choose shellfish over red meat.” Correct Answer (Blank) Question Explanation Rationale: The client with gout should be instructed to avoid foods that are high in purine, which includes organ meats, seafood, fructose, and all alcohol. Concepts tested NCLEX: Basic Care and Comfort Question 6 The nurse is teaching a client about nutritional requirements to promote wound healing. Which dietary choice by the client indicates effective teaching? A baked fish and spinach Correct Answer (Blank) B buttered pasta and fruit cup C grilled cheese sandwich and fried potatoes D ham sandwich and green salad Question Explanation Rationale: To promote wound healing, the nurse should instruct the client to choose foods that are high in protein, carbohydrates, and vitamin C and low in fat. Baked fish is a complete protein, and spinach is a good source of vitamin C. Green salad, grilled cheese, and buttered pasta lack protein. Ham sandwiches and fried potatoes are high in fat. Concepts tested NCLEX: Basic Care and Comfort Question 7 The nurse has educated a client who is newly diagnosed with hypertension about dietary restrictions. The client, who is visually impaired, has requested a written copy of the education. Which action should the nurse take? A Use pictures on the instructions B Provide the instructions in a large print Correct Answer (Blank) C Use simple sentences on the instructions D Provide the instructions at low reading level Question Explanation Rationale: The client, who is visually impaired, that requests a written copy of teaching would benefit from the instructions being in large print. Clients who are health illiterate, or who have decreased reading levels, would benefit from pictures and simple sentences on the instructions. Concepts tested NCLEX: Basic Care and Comfort appropriate? A beef patty on bread, French fries, ½ cup of watermelon, and diet soda B broiled fish, one cup of rice, green beans, and ice water C one cup of cooked pasta with grilled chicken, broccoli, and olive oil, one cup of strawberries, and unsweetened iced tea Correct Answer (Blank) D two cups of lettuce, tomatoes, and cucumbers with ranch dressing and sugar free gelatin with peaches Question Explanation Rationale: Diabetic meal planning exchange lists are an easy way for clients to adequately choose appropriate foods. With the exchange list, the client will choose a number of helpings of food from the list for each meal and snack. The client will choose a starch, fruit, vegetable, meat, fats, and free foods. The meal should include a food from each list. Concepts tested NCLEX: Basic Care and Comfort A white rice B poached eggs C wheat bread Correct Answer (Blank) D baked chicken Question Explanation Rationale: The client with hypothyroidism is at high risk for constipation and should be instructed to eat foods that are high in fiber, such as wheat bread, beans, and broccoli. White rice, poached eggs, and baked chicken are not good sources of fiber and could increase constipation. Concepts tested NCLEX: Basic Care and Comfort The nurse is assisting a client who has a history of pancreatitis with meal planning. Which food choice made by the client would require further teaching? A grilled chicken B cheeseburger Correct Answer (Blank) C vegetable soup D pasta Question Explanation Rationale: The nurse should instruct the client to avoid eating foods high in fat, such as cheese and beef, which can stimulate the pancreas. Foods that are low in fat, such as grilled chicken or vegetable soup or foods that are high in carbohydrates, such as pasta, are less stimulating to the pancreas. Concepts tested NCLEX: Basic Care and Comfort A nurse is performing hourly assessments on a postoperative client with an indwelling catheter. The nurse notes 20 milliliters of urine in the drainage bag since the last assessment. Which action does the nurse perform first? A Prepare to administer a prescribed fluid bolus B Notify the healthcare provider of the output C Perform a bladder scan D Check the catheter tubing for any kinks Correct Answer (Blank) Question Explanation Rationale: The nurse should first ensure the tubing is free of kinks. Urinary catheter tubing that is kinked, or twisted, can prevent the flow of urine into the drainage bag. A fluid bolus is indicated when there are signs of dehydration. The nurse needs to perform additional assessments prior to performing interventions. A bladder scan is indicated when urinary output is decreased and bladder distention is noted. The nurse must first ensure the catheter is functioning properly. The healthcare provider should be notified when urinary output is less than 30 ml/hr. However, the nurse must first perform additional assessments before information the provider of the findings. Concepts tested NCLEX: Basic Care and Comfort Question 12 A nurse is assessing the daily intake and output for a client. The nurse notes that the client’s total fluid intake was 2,000 mL and the client's output was 1,300 mL of urine. Which action should the nurse take? A Document the findings Correct Answer (Blank) B Notify the healthcare provider C Advise the client to increase oral fluid intake D Perform a straight urinary catheterization Question Explanation Rationale: The client’s fluid balance is expected. The excretion of urine makes up approximately half of the daily fluid output. The rest of the fluid loss is via the skin, lungs, and gastrointestinal system. The healthcare provider should be notified when there is a significant imbalance of intake and output. Additional assessments are required to determine an imbalance. Increasing oral fluid intake is not indicated for this client. The urinary output is normal. Urinary catheterization is not indicated. The client is not showing signs of urinary retention. Concepts tested NCLEX: Basic Care and Comfort malnutrition? A White blood cell count of 4,000/mm³ B Hemoglobin level of 10.5 g/dL C Albumin level of 3.1 g/dL Correct Answer (Blank) D Glucose level of 195 mg/dL Question Explanation Rationale: Albumin levels help to determine adequate protein levels and caloric intake. Low albumin levels are indicative of malnutrition. The normal serum albumin level is 4 to 6 g/dL. A low white blood cell (WBC) count is an expected finding for a client receiving chemotherapy. However, a low WBC count is indicative of a risk of infection, not malnutrition. Low hemoglobin levels are an expected finding for a client receiving chemotherapy. However, a low hemoglobin level indicates anemia, not malnutrition. Chemotherapy can cause hyperglycemia. However, a high serum glucose level is not indicative of malnutrition. Concepts tested NCLEX: Basic Care and Comfort Question 14 A nurse is providing care to a client with malnutrition due to chronic alcohol use. The nurse knows that the client’s malnutrition is due to which pathophysiologic factor? A Damage of the intestinal mucosa Correct Answer (Blank) B Blockage of the bile ducts C Increased pressure in the portal vein D Enlargement of esophageal veins Question Explanation Rationale: Alcohol has a toxic effect on the intestinal mucosa. Nutrient absorption occurs in the gastrointestinal system, specifically the small intestine. Fibrotic liver tissue due to alcohol use blocks the bile ducts. Blocked bile ducts result in increased bilirubin levels, not malnutrition. Chronic alcohol use can lead to cirrhosis, which increases the pressure of the portal vein and leads to fluid accumulation in the abdomen. However, this mechanism does not explain malnutrition. Chronic alcohol use causes enlargement of esophageal veins. However, the main concern of esophageal varices is bleeding, not malnutrition. Concepts tested NCLEX: Basic Care and Comfort Question 15 A nurse is providing care to a client with dysphagia. The client coughs frequently during meals and refuses food after a few bites. Which action will best promote adequate nutrition in the client? A Position the client in a high-Fowler’s position B Encourage the client to select their food preferences C Provide liquid nutritional supplements D Request a speech-language pathologist consult Correct Answer (Blank) Question Explanation Rationale: A speech-language pathologist can evaluate the client’s ability to swallow and recommend an appropriate food consistency to promote nutrition and prevent aspiration. Positioning the client in a high-Fowler’s position prevents aspiration of food into the lungs. However, this intervention does not address the client’s difficulty eating. Encouraging the client to select their food preferences promotes independence in eating. This intervention does not resolve the client’s difficulty eating. Liquid nutritional supplements are indicated when a client does not receive enough nutrients. However, the client’s difficulty eating needs to be assessed first. Concepts tested