NCLEX - BASIC CARE AND COMFORT

The nurse is teaching a client who is receiving chemotherapy and has a decreased absolute neutrophil count. Which of the following statements by the client would require follow-up?

• I can eat grilled shrimp once each week.
• I can continue planting flowers in my garden.
• I should shower and apply moisturizer every day.
• I should maintain a consistent intake of steamed vegetables.
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A postoperative client with obesity and diabetes mellitus has an abdominal incision and is at risk for poor wound healing. Which interventions should the nurse include in the plan of care to promote wound healing and prevent dehiscence? Select all that apply.

• Administer docusate PO daily
• Administer ondansetron IV PRN for nausea
• Apply an abdominal binder
• Implement caloric restriction to promote weight loss
• Monitor blood sugar to maintain tight glucose control

The nurse is caring for a group of clients. Which finding requires immediate action by the nurse?

• Client scheduled for discharge who has had a peripheral IV in place for 84 hours
• Client with a do-not-resuscitate prescription who has swelling at the IV site
• Client with a saline lock who had a scheduled IV saline flush due 15 minutes ago
• Client with an IV infusing at 20 mL/hr who has 100 mL fluid remaining in the bag
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The nurse in a long-term care facility is talking with a client with multiple sclerosis who states, "I want to live in my own home again." Which of the following responses would be most appropriate for the nurse to make?

• Do you have family or friends who could live with you?
• I will refer you to a local home-health agency.
• How will you manage your care at home?
• Tell me more about your concerns.
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The nurse is caring for a client who is experiencing an acute exacerbation of chronic low back pain after performing strenuous activity. Which of the following actions should the nurse take?

• Alternate application of hot and cold compresses.
• Advise the client to sleep in the prone position.
• Recommend complete bed rest for the client.
• Request a prescription for opioid analgesics.
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A postoperative client receiving continuous enteral feedings via a nasoenteric tube becomes dyspneic with a productive cough, and crackles are auscultated. Which action is appropriate?

• Administer an inhaled bronchodilator
• Check marked insertion depth of the tube
• Request a prescription for a diuretic
• Start the client on incentive spirometry
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A hospice client refuses food and only sips water. Family insists the client be "force fed." What is the priority nursing action?

• Explain that this is normal in dying clients
• Explore the family's thoughts and concerns
• Recommend a feeding tube
• Tell the family the client could choke
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UAP reports a reddened sacral area. What is the nurse’s priority action?

• Direct UAP to apply protective foam
• Document Braden Scale results
• Notify the HCP
• Perform a skin assessment
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Client and spouse are crying after receiving an Alzheimer diagnosis. What is the nurse’s best response?

• Do you have any questions about the diagnosis?
• There are medications available to treat Alzheimer disease.
• This new diagnosis must be frightening for you.
• We can help you make decisions about your care.
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Client expresses concern about facial appearance after melanoma surgery. What is the best nurse response?

• Have you shared concerns with your HCP?
• If I were you, I’d worry about the cancer spreading.
• Scar tissue is normal; we’ll teach wound care.
• There’s special makeup to hide facial scars.
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