Basic Care and Comfort
Basic Care and Comfort
1. The nurse is planning care for a client with a cerebral vascular accident (CVA). Which of the following measures
planned by the nurse would be most effective in preventing skin breakdown?
A) Place client in the wheelchair for four hours each day
B) Pad the bony prominence
C) Reposition every two hours
D) Massage reddened bony prominence
2. After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is
A) abdominal x-ray
B) auscultation
C) flushing tube with saline
D) aspiration for gastric contents
3. The nurse has been teaching a client with congestive heart failure about proper nutrition. Which of these lunch
selections indicates the client has learned about sodium restriction?
A) Cheese sandwich with a glass of 2% milk
B) Sliced turkey sandwich and canned pineapple
C) Cheeseburger and baked potato
D) Mushroom pizza and ice cream
4. The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and
oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate?
A) Decreased carbohydrates and fat
B) Decreased sodium and potassium
C) Increased potassium and protein
D) Increased sodium and fluids
5. After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is teaching the client
about the diet, which meal plan would be the most appropriate to suggest?
A) 3 oz. broiled fish, 1 baked potato, ½ cup canned beets, 1 orange, and milk
B) 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple
C) A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice
D) 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange
6. What finding of the nursing assessment of a paralyzed client would indicate the probable presence of a fecal
impaction?
A) Presence of blood in stools
B) Oozing liquid stool
C) Continuous rumbling flatulence
D) Absence of bowel movements
7. The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice
indicates the client understands dietary needs?
A) three apricots
B) medium banana
C) naval orange
D) baked potato
8. When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula
A) every four to six hours
B) continuously
C) in a bolus
D) every hour
9. An 86 year-old nursing home resident who has impaired mental status is hospitalized with pneumonic infiltrates in
the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should
the nurse do next?
A) Add a thickening agent to the fluids
B) Check the client’s gag reflex
C) Feed the client only solid foods
D) Increase the rate of intravenous fluids
10. An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse should be
A) assess the severity and location of the pain
B) obtain an order for an analgesic
C) reassure him that this is not unusual for his age
D) encourage him to increase his activity
11. A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile-colored liquids.
Which
nursing measure will provide the most comfort to the client?
A) Allow the client to melt ice chips in the mouth
B) Provide mints to freshen the breath
C) Perform frequent oral care with a tooth sponge
D) Swab the mouth with glycerin swabs
12. The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction
regarding exercise would be to
A) exercise doing weight bearing activities
B) exercise to reduce weight
C) avoid exercise activities that increase the risk of fracture
D) exercise to strengthen muscles and thereby protect bones
13. A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for
development of decubitus ulcers?
A) A 79 year-old malnourished client on bed rest
B) An obese client who uses a wheelchair
C) An incontinent client who has had 3 diarrhea stools
D) An 80 year-old ambulatory diabetic client
14. Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should
be the nurse's priority?
A) obtain a complete blood count
B) obtain a health and dietary history
C) refer to a provider for a physical examination
D) measure height and weight
15. A nurse is working with a client in an extended care facility. Which bed position is preferred for a client, who is at
risk for falls, as part of a prevention protocol?
A) All 4 side rails up, wheels locked, bed closest to door
B) Lower side rails up, bed facing doorway
C) Knees bent, head slightly elevated, bed in lowest position
D) Bed in lowest position, wheels locked, place bed against wall
16. The nurse is teaching an 87 year-old client methods for maintaining regular bowel movements. The nurse would
caution the client to avoid
A) glycerine suppositories
B) fiber supplements
C) laxatives
D) stool softeners
19. A client is being maintained on heparin therapy for deep vein thrombosis (DVT). The nurse must closely monitor
which of the following laboratory values?
A) bleeding time
B) platelet count
C) activated PTT
D) clotting time
20. A client in a long term care facility complains of pain. The nurse collects data about the client’s pain. The first
step in pain
assessment is for the nurse to
A) have the client identify coping methods
B) get the description of the location and intensity of the pain
C) accept the client’s report of pain
D) determine the client’s status of pain