Free NCLEX-RN Basic Care & Comfort Questions
Free NCLEX-RN basic care and comfort practice questions with rationales — mobility, nutrition, hygiene, rest, and comfort measures.
A client with advanced cancer on comfort-focused care has dyspnea and an oxygen saturation of 90 percent. The family is anxious. Which action best supports the client's comfort?
Correct answer: D
In comfort-focused care the goal is to relieve the sensation of breathlessness, not to normalize a number. Sitting upright, moving air across the face with a fan, and giving the prescribed low-dose opioid are the evidence-based measures that ease air hunger. Chasing an oxygen saturation above 95 percent treats the monitor rather than the client, withholding the opioid undertreats the dyspnea, and pushing activity increases the work of breathing.
Why the other options are wrong
- A. Comfort care aims to relieve the sensation of breathlessness, not to reach a target saturation number.
- B. Low-dose opioids relieve air hunger in palliative dyspnea; withholding them undertreats the client.
- C. Increasing activity raises the work of breathing and worsens the dyspnea.
Key takeaway: For palliative dyspnea, relieve the sensation of breathlessness with positioning, a fan, and a low-dose opioid. Do not chase the oxygen saturation number or withhold opioids.
A client receives several oral medications through a percutaneous endoscopic gastrostomy (PEG) tube. Which action by the nurse is correct?
Correct answer: D
Medications are given through a feeding tube one at a time, with a water flush before, between, and after, to prevent clogging and drug interactions in the tube. Enteric-coated and extended-release forms are never crushed or opened, because that destroys the coating or the timed-release mechanism and can cause a dangerous rapid dose. Flushing only once at the end, instead of between each medication, lets the drugs interact and clog the tube.
Why the other options are wrong
- A. An enteric-coated tablet is not crushed; crushing removes the protective coating.
- B. Flushing only after the last medication lets drugs mix and clog the tube; flush before, between, and after each one.
- C. An extended-release capsule is not opened or crushed; doing so releases the full dose at once.
Key takeaway: Give tube medications separately with water flushes between them. Never crush enteric-coated or extended-release forms, and do not mix medications together.
An immobile client on bed rest has several new findings. Which requires the most urgent nursing action?
Correct answer: B
A warm, swollen, tender calf in an immobile client suggests a deep vein thrombosis, which can dislodge and cause a life-threatening pulmonary embolism, so it is the most urgent finding; the nurse avoids massaging or exercising the leg and notifies the provider. The sacral redness is an early pressure injury needing offloading, the diminished breath sounds suggest atelectasis needing deep breathing and incentive spirometry, and two days without a bowel movement needs attention, but none carries the immediate risk of the possible DVT.
Why the other options are wrong
- A. A stage 1 pressure injury needs offloading and prevention, but it is not the most urgent of these findings.
- C. Constipation needs intervention but is not an immediate life threat.
- D. Atelectasis needs deep breathing and incentive spirometry, but the possible DVT poses the more immediate danger.
Key takeaway: Among immobility complications, a possible DVT (warm, swollen, tender calf) is most urgent because of the risk of a fatal pulmonary embolism. Do not massage the leg; notify the provider.
A client has been on bed rest for 3 days after pneumonia. During the first attempt to get the client to a chair, the nurse notes a supine blood pressure of 128/76 mm Hg and pulse of 84/min. When sitting, the blood pressure is 94/58 mm Hg, pulse is 112/min, and the client reports lightheadedness. What should the nurse do?
Correct answer: A
The client has symptomatic orthostatic hypotension: a large blood pressure drop, compensatory tachycardia, and lightheadedness on sitting. The nurse should stop the transfer attempt, assist the client safely back to bed, reassess, and report the change so the mobility plan can be adjusted. Standing or continuing the transfer creates a fall risk, leaving the client sitting alone is unsafe, and a cane does not correct the unstable vital signs.
Why the other options are wrong
- B. Standing a dizzy client with a large orthostatic blood pressure drop increases fall risk.
- C. A lightheaded client with orthostatic changes should not be left sitting alone.
- D. A cane does not address the symptomatic orthostatic hypotension and is not enough support for this first transfer attempt.
Key takeaway: Before mobilizing a bed-rested client, interpret orthostatic cues. Symptomatic blood pressure drop plus tachycardia means stop the transfer, keep the client safe, reassess, and report.
A client who had gastric surgery is taught how to prevent dumping syndrome. Which instructions should the nurse include? Select all that apply.
Correct answers: o1, o2, o3, o5
Dumping syndrome happens when food moves too quickly into the small intestine after gastric surgery. Small frequent meals, drinking fluids between (not with) meals, lying down briefly after eating, and including protein and fat all slow gastric emptying and reduce symptoms. Simple sugars and sweet drinks pull fluid into the gut and trigger dumping, so they are avoided.
Why the other options are wrong
- o4. Simple sugars are rapidly broken down and emptied into the duodenum, creating a hypertonic environment that triggers osmotic fluid shifts and dumping symptoms. Key distinction: Complex carbohydrates should be substituted because they empty more slowly.
- o6. Sweet juices contain simple sugars that rapidly draw fluid into the intestinal lumen, causing sudden cramping and diarrhea. Key distinction: Liquids should be sugar-free and consumed between meals rather than during meals.
Key takeaway: Prevent dumping syndrome: small frequent meals, fluids between meals, lie down after eating, add protein/fat, avoid simple sugars.
A client with dysphagia and right-sided weakness is starting oral intake with prescribed thickened liquids. Which actions should the nurse include to support safe intake? Select all that apply.
Correct answers: o2, o3, o1
Safe dysphagia intake controls position, pace, and rescue capability. Upright positioning during and after the meal uses gravity to keep the bolus moving away from the airway. Fatigue and a wet voice signal a tiring or unsafe swallow, so rest breaks prevent aspiration late in the meal. Suction at the bedside is the rescue measure if the client does aspirate.
Why the other options are wrong
- o4. Tilting the head back extends the neck and opens the airway, which makes aspiration more likely. Safe swallowing uses a chin-tuck with the head slightly forward.
- o5. A straw delivers a fast, uncontrolled bolus to the back of the throat and increases aspiration risk in dysphagia.
- o6. An intact gag reflex does not confirm a safe, coordinated swallow, and a client can aspirate despite having one. Testing it before every sip checks the wrong thing and delays the meal.
Key takeaway: For dysphagia, secure position, pacing, and suction. Head-back positioning, straws, and leaning on the gag reflex are common traps that raise aspiration risk.
The nurse assesses a sacral area with intact skin showing a localized, persistent, nonblanchable dark maroon discoloration. The area is boggy and warmer than the surrounding tissue. How should the nurse document this finding?
Correct answer: A
Stage by what the tissue tells you. Intact skin with persistent deep maroon or purple color that is boggy and warm reflects damage in the tissue below the surface, which defines a deep tissue pressure injury. The color is darker and the area is boggy rather than the bright, firm redness of stage 1.
Why the other options are wrong
- B. Stage 1 is nonblanchable redness of intact skin, but the color is a defined pink or red and the tissue is not boggy or maroon. The deep discoloration here signals damage below the surface.
- C. Stage 2 is partial-thickness skin loss with an open or blistered wound bed. This skin is still intact, so it cannot be stage 2.
- D. Unstageable means full-thickness loss whose depth is hidden by slough or eschar. There is no wound or covering here, so depth is not obscured.
Key takeaway: Intact skin plus deep maroon or purple color that is boggy and warm is a deep tissue pressure injury, not stage 1. Open skin is needed for stage 2, and hidden depth under eschar is needed for unstageable.