Free NCLEX-RN practice
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.
11 basic care & comfort practice questions with rationales
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.
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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 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 nurse is feeding a client who has dysphagia following an ischemic stroke. To reduce the client's risk of aspiration during the meal, which action should the nurse take?
Correct answer: C
Rule: the safest swallow in dysphagia uses a chin-tuck (chin-down) posture with the client sitting fully upright, thickened liquids, and small bites; anything that speeds the bolus or opens the airway raises aspiration risk. Applying it to this client, tucking the chin toward the chest with each swallow narrows the airway entrance and directs food away from the trachea, so it is the action that most reduces aspiration during the meal.
Why the other options are wrong
- A. Thin liquids feel like they would help wash food down, but they move fast and are the hardest consistency to control, so they are the most commonly aspirated. Dysphagia diets thicken liquids for exactly this reason.
- B. A 30-degree semi-Fowler angle looks like a comfortable resting position, but eating safely requires the client fully upright near 90 degrees so gravity helps the bolus travel down. Reclining invites pooling and aspiration.
- D. Tilting the head back seems to move food toward the throat, but head extension opens the airway and lines the trachea up with the bolus, the opposite of what a client who already struggles to protect the airway needs.
Key takeaway
For dysphagia, sit the client fully upright, use a chin-tuck, thicken liquids, and keep bites small; thin liquids and head extension are the classic aspiration traps.
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.
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 82-year-old client has been immobile for several days after a hip fracture. During a skin assessment, the nurse notes a 3-cm area over the sacrum where the skin is intact but shows a localized, non-blanchable maroon-to-purple discoloration. The underlying tissue feels boggy and is cooler than the surrounding skin. There is no open wound, slough, or eschar. How should the nurse document this finding?
Correct answer: C
Rule: a localized area of intact (or non-intact) skin with persistent non-blanchable deep red, maroon, or purple discoloration signals damage that began at the bone-muscle interface, which is a deep tissue pressure injury. The tissue often feels boggy, firm, or mushy and may be warmer or cooler than nearby skin before any wound opens. This client shows all of those cues: intact skin, deep maroon-purple color that does not blanch, and boggy cooler tissue. That pattern is deep tissue injury, not a surface stage.
Why the other options are wrong
- A. Stage 1 is also intact skin with a non-blanchable change, but Stage 1 is redness only, not the deep maroon-purple color with boggy underlying tissue, which shows the damage is deep rather than superficial.
- B. Stage 2 is an early, shallow lesion, but Stage 2 needs partial-thickness skin loss with an open red-pink wound bed or a serum-filled blister, and this client's skin is intact.
- D. Both terms describe damage of uncertain depth, but unstageable requires a full-thickness wound whose base is hidden by slough or eschar; here the skin is intact with no wound bed at all.
Key takeaway
Intact skin with deep maroon or purple non-blanchable color plus boggy tissue is a deep tissue pressure injury; Stage 1 is redness only, and unstageable needs slough or eschar over an open wound.
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.
A client with chronic insomnia asks how to reset a sleep schedule that has drifted later each week. Which instruction should the nurse give first?
Correct answer: B
A fixed morning wake time anchors the circadian clock and rebuilds nighttime sleep drive. Sleeping in on weekends, going to bed much earlier while still not sleepy, or staying in bed until an arbitrary 8-hour total all lengthen time in bed awake and push the schedule later. The schedule reset starts with a consistent rise time; bedtime follows once sleepiness returns at night.
Why the other options are wrong
- A. Sleeping in on weekends feels restorative, but it delays the body clock and makes Monday night insomnia worse. Keep the wake time steady every day.
- C. An earlier bedtime seems to buy more sleep, but going to bed long before sleepiness returns adds awake time in bed and lowers sleep efficiency. Fix the wake time first, then let bedtime follow sleepiness.
- D. Staying in bed until 8 hours accumulate rewards a late schedule and trains the brain to link the bed with long wakeful stretches. Rise at a set time and get out of bed when sleep ends.
Key takeaway
To reset a drifted sleep schedule, keep the same morning wake time every day, including weekends; do not sleep in, pad bedtime early, or stay in bed chasing an 8-hour total.
A nurse is assisting a client with cleaning and storing removable dentures. Which action by the nurse demonstrates correct technique?
Correct answer: A
Rule first: dentures are slippery and brittle, so every step aims to protect them from breakage, warping, and drying. Cushioning the sink with water or a towel protects the dentures if they slip from the hands during cleaning, which is the moment they are most likely to shatter. Hot water warps the acrylic and changes the fit, storing them dry lets them dry out and warp and invites accidental discard, and whitening or other abrasive toothpastes scratch the surface and create grooves that trap bacteria. Only the cushioned sink protects the dentures without harming them.
Why the other options are wrong
- B. Hot water feels like it would clean and disinfect, but heat warps the acrylic and distorts the fit. Dentures are cleaned in cool or lukewarm water.
- C. A dry napkin seems to keep the dentures safe, but dentures dry out and warp when stored dry and are easily thrown away by mistake. They are stored in water or a soaking solution.
- D. Whitening toothpaste sounds like it would remove stains, but its abrasives scratch the denture surface, leaving grooves that harbor bacteria. A soft brush with a nonabrasive cleanser is used instead.
Key takeaway
Protect dentures from breakage, warping, and drying: cushion the sink with water or a towel while cleaning, use cool water and a nonabrasive cleanser, and store them in water or soaking solution, never dry or in hot water.
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.