NCLEX-RN Basic Care and Comfort practice questions

Question 1

A 68-year-old client with a recent right hip replacement is 2 days postoperative. The nurse observes the client attempting to get out of bed independently by twisting the right leg toward the floor. Which action should the nurse take first?

1. A Assist the client back into bed and reinforce the need to use the trapeze bar for repositioning.
2. B Call the charge nurse to report the client's noncompliance with postoperative hip precautions.
3. C Place a pillow between the client's legs before allowing the client to stand to prevent dislocation.
4. D Apply an abduction pillow and instruct the client to logroll to the side of the bed before standing.

Question 2

A 72-year-old client with a history of chronic obstructive pulmonary disease is admitted with pneumonia and has an oxygen saturation of 89% on room air. The nurse applies supplemental oxygen at 2 L/min via nasal cannula. Which position should the nurse place the client to optimize breathing and comfort?

1. A High Fowler's position with the head of the bed at 90 degrees and arms supported on pillows.
2. B Left lateral recumbent position with the upper leg flexed and a pillow between the knees.
3. C Semi-Fowler's position with the head of the bed at 30 degrees and the feet elevated.
4. D Supine with the head of the bed flat and a small pillow under the knees.

Question 3

A 78-year-old client with a history of falls is being discharged home after a hip fracture repair. The client has weakness in the right leg and uses a walker. Which instruction should the nurse include in discharge teaching?

1. A Advance the walker and the right leg together, then bring the left leg forward.
2. B Place the walker one step ahead and step forward with the left leg first.
3. C Use the walker only when feeling unsteady to preserve arm strength.
4. D Hold the walker in the stronger hand and the cane in the weaker hand.

Question 4

A 74-year-old client is bedridden after a hip fracture repair. The nurse performs a skin assessment and notes a non-blanchable area of redness over the sacrum that is intact but feels warm to the touch. The client reports mild discomfort in the area. Which nursing action is most appropriate?

1. A Turn the client every 2 hours and place a pressure-relieving cushion under the sacrum.
2. B Apply a transparent film dressing to protect the skin from further friction.
3. C Clean the area with an antiseptic cleanser and apply a barrier cream.
4. D Massage the reddened area with lotion to improve circulation and prevent breakdown.

Question 5

A 72-year-old client admitted with a right-sided ischemic stroke has left-sided weakness and requires assistance to ambulate. The client's blood pressure is 138/82 mm Hg, heart rate 88/min, and oxygen saturation 96% on room air. Which nursing action best promotes safe ambulation?

1. A Apply a gait belt around the client's waist and walk on the client's weaker side.
2. B Stand on the client's stronger side and hold the client's hand while walking.
3. C Instruct the client to slide the left foot forward while the nurse supports the right arm.
4. D Use a transfer board to slide the client from the bed to a wheelchair for mobility.

Question 6

A 58-year-old client with type 2 diabetes and peripheral neuropathy is admitted with a Stage 3 pressure injury on the left heel. The wound bed is 75% red granulation tissue with 25% yellow slough, moderate serosanguineous drainage, and no odor. Which dressing product is most appropriate for the nurse to apply?

1. A Gauze moistened with 0.9% sodium chloride and packed loosely into the wound.
2. B Calcium alginate dressing covered with a secondary foam dressing.
3. C Transparent film dressing changed once every 7 days.
4. D Hydrocolloid dressing cut to size and left in place for 5 days.

Question 7

A 72-year-old client in a long-term care facility has been on bed rest for three days after a fall. The nurse notes a 2 cm area of nonblanchable erythema over the coccyx. Which nursing action should be implemented first?

1. A Place a donut-shaped cushion under the sacrum to relieve pressure.
2. B Reposition the client to a 30-degree lateral side-lying position.
3. C Massage the reddened area with moisturizing lotion twice daily.
4. D Apply a transparent wound barrier over the coccyx area.

Question 8

A 48-year-old male client with a history of hypertension is admitted with hypernatremia (serum sodium 154 mEq/L) and dehydration. He is alert and oriented, with a blood pressure of 110/70 mm Hg, heart rate 98/min, and dry oral mucosa. Which nursing intervention should the nurse implement first?

1. A Administer 0.9% sodium chloride intravenously at 100 mL/hr as prescribed.
2. B Provide a clear liquid diet containing broth and gelatin.
3. C Restrict all oral intake and prepare for hemodialysis.
4. D Offer the client 120 mL of water with crushed ice every hour while awake.

Question 9

A 50-year-old male in a cardiac step-down unit after a myocardial infarction complains of difficulty falling asleep due to noise and anxiety. His vital signs are stable. Which nursing intervention is most appropriate to promote sleep?

1. A Encourage the client to watch television until sleepy
2. B Offer a caffeinated beverage to relax before bed
3. C Administer zolpidem 5 mg at bedtime
4. D Close the door and dim the lights at 9 PM

Question 10

A 78-year-old female client in a long-term care facility has limited mobility and is unable to perform her own oral care. The nurse delegates oral care to a nursing assistant. Which observation by the nurse indicates that the nursing assistant is providing safe and effective oral hygiene for this client?

1. A The nursing assistant positions the client in a high Fowler's position and uses a foam swab with mouthwash.
2. B The nursing assistant applies a lemon-glycerin swab to the client's oral mucosa to stimulate saliva production.
3. C The nursing assistant uses a soft toothbrush with fluoride toothpaste and brushes the client's teeth for two minutes.
4. D The nursing assistant places the client in a supine position and uses a firm toothbrush with baking soda.