NACE Basic Care and Comfort 5 — Questions and Answers
Question 1: A nurse is caring for a client on bed rest after surgery. Which action BEST prevents venous thromboembolism (VTE)?
- Encourage the client to remain still to avoid pain
- Apply sequential compression devices (SCDs) as ordered (Correct answer)
- Massage the calves vigorously twice per shift
- Elevate the foot of the bed 30 degrees at all times
Correct answer: Apply sequential compression devices (SCDs) as ordered
Sequential compression devices promote venous return and are a primary mechanical intervention to prevent VTE in immobile clients.
Question 2: A nurse is caring for a client who is visually impaired. Which approach is MOST appropriate when assisting with ambulation?
- Walk slightly ahead and guide the client by the wrist
- Walk slightly behind the client and place hands on their shoulders
- Allow the client to hold the nurse's elbow and walk slightly behind (Correct answer)
- Walk beside the client and describe the environment verbally only
Correct answer: Allow the client to hold the nurse's elbow and walk slightly behind
The sighted-guide technique has the client hold the guide's elbow and walk a half-step behind, providing safe and dignified navigation.
Question 3: A nurse is assessing a client's nutritional status. Which finding is the BEST indicator of chronic protein-calorie malnutrition?
- Recent weight loss of 2 lb over 1 week
- Serum albumin level of 2.8 g/dL (Correct answer)
- Complaint of decreased appetite for 2 days
- Blood glucose of 110 mg/dL fasting
Correct answer: Serum albumin level of 2.8 g/dL
Serum albumin reflects protein stores over 2–3 weeks and a level below 3.5 g/dL indicates chronic malnutrition.
Question 4: A nurse is inserting a urinary catheter in a female client. After cleansing the urinary meatus, the catheter accidentally touches the labia. What is the CORRECT action?
- Wipe the catheter tip with a sterile gauze and continue insertion
- Advance the catheter quickly before contamination spreads
- Discard the catheter and obtain a new sterile catheter (Correct answer)
- Irrigate the catheter with sterile saline and proceed
Correct answer: Discard the catheter and obtain a new sterile catheter
Any contact with a non-sterile surface contaminates the catheter, requiring a new sterile catheter to prevent urinary tract infection.
Question 5: A client with a new colostomy expresses embarrassment about odor. Which nurse response is MOST therapeutic?
- Reassure the client that others cannot smell it
- Teach the client about dietary modifications and odor-control pouches (Correct answer)
- Encourage the client to avoid social situations until adjusted
- Suggest the client limit fluid intake to reduce output
Correct answer: Teach the client about dietary modifications and odor-control pouches
Educating the client about diet and odor-control products empowers self-management and addresses the concern directly.
Question 6: A nurse is caring for a client receiving enteral tube feedings. Which assessment finding warrants IMMEDIATE action?
- Residual gastric volume of 100 mL
- Bowel sounds present in all four quadrants
- Abdomen that is firm, distended, and silent (Correct answer)
- Client reports mild nausea after feeding rate increase
Correct answer: Abdomen that is firm, distended, and silent
A firm, distended, silent abdomen suggests ileus or obstruction, which can cause aspiration or perforation and requires immediate intervention.
Question 7: A nurse is teaching a client about incentive spirometry after abdominal surgery. Which instruction is CORRECT?
- Exhale forcefully into the device to measure lung capacity
- Use the device once each morning after waking
- Inhale slowly and deeply to raise the piston, then hold for 3–5 seconds (Correct answer)
- Breathe rapidly and shallowly to increase respiratory rate
Correct answer: Inhale slowly and deeply to raise the piston, then hold for 3–5 seconds
Slow, deep inhalation followed by a brief breath-hold maximizes alveolar expansion and prevents atelectasis.
NACE Basic Care and Comfort 5
A nurse is caring for a client on bed rest after surgery.
Which action BEST prevents venous thromboembolism (VTE)?