NCLEX BASIC CARE AND COMFORT EXAM 2024 WITH 100% CORRECT ANSWERS
The primary healthcare provider (PHP) has prescribed a saline IM injection for a client who requests pain
medication every 2-3 hours. What would be the nurse's best first action?
1. Administer the injection.
2. Take vital signs.
3. Question prescription with primary healthcare provider.
4. Notify the nursing supervisor. - correct answer ✔✔ 3. Question prescription with primary healthcare provider.
(3. Correct: A placebo is any medication or procedure that produces an effect in clients resulting from its
implicit or explicit intent and not from its physical or chemical properties. An example would be a sugar pill or injection of saline. Some professionals try to justify the use of placebos to elicit the desirable placebo effect or in a misguided attempt to determine if the client's pain is real. These reasons cannot be justified on either a clinical or ethical basis, except in an approved research study. It is deceptive and represents fraudulent and unethical treatment.
1. Incorrect: Giving a placebo is fraudulent and unethical treatment.
2. Incorrect: Taking the vital signs does not take care of the problem of giving a placebo.
4. Incorrect: First, the nurse should discuss the prescription with the primary healthcare provider.)
Which suggestion should the nurse provide to a client reporting frequent episodes of constipation? 1. Take a stool softener.
2. Increase intake of fruit in the diet.
3. Monitor elimination habits for the next week.
4. Rest after each meal. - correct answer ✔✔ 2. Increase intake of fruit in the diet.
(2. Correct: Increased fiber intake may help to establish regular elimination habits.
1. Incorrect: Not the best initial suggestion. It's better to promote health maintenance routines than to just go with a medication, which could be a temporary fix.
3. Incorrect: The nurse should make a suggestion that will assist the client with normal elimination. This option does not suggest a way to fix the problem.
4. Incorrect: Increased activity is likely to result in more normal elimination. Resting after meals would not increase elimination frequency.)
The nurse is administering medication to an elderly client who has no visitors. The client takes the pills, and, as the client hands the medication cup back to the nurse, grabs onto the nurse's hand tightly. What is the most logical rationale for the client's action?
1. Confusion and disorientation.
2. Scared and lonely and grabs the nurse's hand for comfort.
3. Would like to talk with the nurse. 4. Would like to reminisce with the nurse. - correct answer ✔✔ 2. Scared and lonely and grabs the nurse's hand for comfort.
(2. Correct: This elderly client with no visitors is most likely scared and lonely. The touch of the nurse's hand is comforting for the client.
1. Incorrect: There is no indication of confusion or disorientation.
3. Incorrect: Grabbing the nurse's hand indicates more than just a desire to talk. This is indicative of needing comfort and personal touch.
4. Incorrect: There is no indication of a desire to reminisce from the information in the question.)
A nurse has educated a client on crutch walking. Which statement by the client would indicate to the nurse that the client needs further instruction?
1. "I will not alter the height of my crutches."
2. "My body weight should be supported at the hand grips with my elbows flexed at 30 degrees."
3. "When I rise from a chair, I should position my crutches on my unaffected side."
4. "I will not lean on my crutches while standing." - correct answer ✔✔ 3. "When I rise from a chair, I should position my crutches on my unaffected side."
(3. Correct: The client should position crutches on affected side when sitting or rising from a chair. This will give the client more stability with position changes.
1. Incorrect: This is a correct statement by the client. Once the crutches have been properly fitted, they should not be altered by the client.
The primary healthcare provider (PHP) has prescribed a saline IM injection for a client who requests pain
medication every 2-3 hours. What would be the nurse's best first action?
1. Administer the injection.
2. Take vital signs.
3. Question prescription with primary healthcare provider.
4. Notify the nursing supervisor. - correct answer ✔✔ 3. Question prescription with primary healthcare provider.
(3. Correct: A placebo is any medication or procedure that produces an effect in clients resulting from its
implicit or explicit intent and not from its physical or chemical properties. An example would be a sugar pill or injection of saline. Some professionals try to justify the use of placebos to elicit the desirable placebo effect or in a misguided attempt to determine if the client's pain is real. These reasons cannot be justified on either a clinical or ethical basis, except in an approved research study. It is deceptive and represents fraudulent and unethical treatment.
1. Incorrect: Giving a placebo is fraudulent and unethical treatment.
2. Incorrect: Taking the vital signs does not take care of the problem of giving a placebo.
4. Incorrect: First, the nurse should discuss the prescription with the primary healthcare provider.)
Which suggestion should the nurse provide to a client reporting frequent episodes of constipation? 1. Take a stool softener.
2. Increase intake of fruit in the diet.
3. Monitor elimination habits for the next week.
4. Rest after each meal. - correct answer ✔✔ 2. Increase intake of fruit in the diet.
(2. Correct: Increased fiber intake may help to establish regular elimination habits.
1. Incorrect: Not the best initial suggestion. It's better to promote health maintenance routines than to just go with a medication, which could be a temporary fix.
3. Incorrect: The nurse should make a suggestion that will assist the client with normal elimination. This option does not suggest a way to fix the problem.
4. Incorrect: Increased activity is likely to result in more normal elimination. Resting after meals would not increase elimination frequency.)
The nurse is administering medication to an elderly client who has no visitors. The client takes the pills, and, as the client hands the medication cup back to the nurse, grabs onto the nurse's hand tightly. What is the most logical rationale for the client's action?
1. Confusion and disorientation.
2. Scared and lonely and grabs the nurse's hand for comfort.
3. Would like to talk with the nurse. 4. Would like to reminisce with the nurse. - correct answer ✔✔ 2. Scared and lonely and grabs the nurse's hand for comfort.
(2. Correct: This elderly client with no visitors is most likely scared and lonely. The touch of the nurse's hand is comforting for the client.
1. Incorrect: There is no indication of confusion or disorientation.
3. Incorrect: Grabbing the nurse's hand indicates more than just a desire to talk. This is indicative of needing comfort and personal touch.
4. Incorrect: There is no indication of a desire to reminisce from the information in the question.)
A nurse has educated a client on crutch walking. Which statement by the client would indicate to the nurse that the client needs further instruction?
1. "I will not alter the height of my crutches."
2. "My body weight should be supported at the hand grips with my elbows flexed at 30 degrees."
3. "When I rise from a chair, I should position my crutches on my unaffected side."
4. "I will not lean on my crutches while standing." - correct answer ✔✔ 3. "When I rise from a chair, I should position my crutches on my unaffected side."
(3. Correct: The client should position crutches on affected side when sitting or rising from a chair. This will give the client more stability with position changes.
1. Incorrect: This is a correct statement by the client. Once the crutches have been properly fitted, they should not be altered by the client.
