Nursing Acceleration Challenge Exam I PN-RN Basic Care and Comfort Questions and Answers 1 — Questions and Answers
Question 1: A nurse is caring for a client who had a stroke and has dysphagia. Which of the following interventions is the priority to ensure the client's safety and comfort during meals?
- Ensuring the client is in a high-Fowler's position. (Correct answer)
- Providing thin liquids to make swallowing easier.
- Encouraging the client to eat quickly to prevent fatigue.
- Placing food on the affected side of the mouth.
Correct answer: Ensuring the client is in a high-Fowler's position.
Positioning the client in a high-Fowler's position (sitting upright at 90 degrees) uses gravity to aid in swallowing and is the most critical intervention to prevent aspiration in a client with dysphagia. Thin liquids are difficult to control and increase aspiration risk. The client should eat slowly and take small bites. Food should be placed on the unaffected, stronger side of the mouth to facilitate better control.
Question 2: A postoperative client is encouraged to ambulate as soon as possible. Which of the following is the primary rationale for early ambulation?
- To increase the client's appetite.
- To prevent postoperative complications like deep vein thrombosis (DVT). (Correct answer)
- To decrease the need for pain medication.
- To improve the client's social interaction.
Correct answer: To prevent postoperative complications like deep vein thrombosis (DVT).
Early ambulation is crucial for preventing serious postoperative complications. It stimulates circulation, which helps prevent the formation of blood clots (deep vein thrombosis) in the legs. While it may indirectly affect appetite, pain, and social interaction, the primary medical reason is to prevent complications such as DVT, atelectasis, and pneumonia.
Question 3: A nurse is developing a plan of care for an older adult client at risk for pressure injuries. Which of the following interventions should be included?
- Massaging bony prominences to increase circulation.
- Repositioning the client every 4 hours.
- Using donut-shaped cushions for seating.
- Keeping the skin clean and dry and using a moisturizer. (Correct answer)
Correct answer: Keeping the skin clean and dry and using a moisturizer.
Maintaining skin integrity by keeping it clean, dry, and well-moisturized is a fundamental aspect of pressure injury prevention. Massaging bony prominences is contraindicated as it can cause tissue damage. At-risk clients should be repositioned more frequently, typically every 2 hours. Donut-shaped cushions are avoided because they can impair blood flow.
Question 4: When teaching a client how to use a standard cane, the nurse should instruct the client to hold the cane on which side?
- On the affected (weaker) side.
- On the unaffected (stronger) side. (Correct answer)
- On whichever side feels more comfortable.
- Alternating sides with each step.
Correct answer: On the unaffected (stronger) side.
The cane should be held on the client's stronger (unaffected) side to provide the best support and stability. The cane then moves forward with the weaker leg, creating a wide base of support and allowing the client to lean on the stronger side.
Question 5: A client is reporting pain rated at 8 on a 0-10 scale. After administering the prescribed analgesic, which non-pharmacological intervention would be most appropriate for the nurse to implement to provide additional comfort?
- Encouraging the client to take a long walk.
- Suggesting the client watch television as a distraction. (Correct answer)
- Applying a cold pack to the surgical site from 4 hours ago.
- Starting a rigorous physical therapy session.
Correct answer: Suggesting the client watch television as a distraction.
Distraction techniques, such as watching television or listening to music, can be effective non-pharmacological methods to help manage pain by shifting the client's focus away from the discomfort. Vigorous activity like a long walk or physical therapy would likely exacerbate acute pain. Applying a cold pack may be appropriate, but distraction is a versatile comfort measure that can be implemented easily.
Question 6: A nurse is providing hygiene care to an unconscious client. Which action is essential to prevent injury?
- Soaking the feet in hot water to soften the skin.
- Using lemon-glycerin swabs for oral care.
- Providing perineal care from the rectum toward the urethra.
- Having another staff member present to help with turning and positioning. (Correct answer)
Correct answer: Having another staff member present to help with turning and positioning.
Turning and positioning an unconscious client requires at least two staff members to ensure the client's safety, prevent musculoskeletal injury to both the client and the staff, and maintain proper body alignment. Hot water can cause burns, especially in clients with decreased sensation. Lemon-glycerin swabs can dry out the oral mucosa. Perineal care should be performed from the urethra toward the rectum (front to back) to prevent urinary tract infections.
Nursing Acceleration Challenge Exam I PN-RN Basic Care and Comfort Questions and Answers 1
A nurse is caring for a client who had a stroke and has dysphagia.
Which of the following interventions is the priority to ensure the client's safety and comfort during meals?