NCLEX Practice Test for Basic Care and Comfort 2023 (40 Questions with Explained Answers)

welcome to the 2023 NCLEX basic care and comfort practice test this test will have 40 questions with explained answers that will help you prepare for the test be sure to resuscitate the like button by turning it white question one a 16 year old comes into the Ed with severe abdominal pain to the right lower quadrant what is your initial step when assessing this patient a palpate b auscultate c perkas d inspect the correct answer is D inspect the first step in assessing the abdomen is to inspect as percussing and auscultating can alter the bowel pattern after inspecting auscultation should be done followed by percussing and then palpitation question two who should the numerical Pain Scale be used on a a non-verbal six-year-old patient B an intubated patient c a patient in a doctor's office who is upset d a deaf 10 year old with developmental delays the correct answer is c a patient in a doctor's office who is upset the numerical Pain Scale is best used for adult patients other pain scales like the non-verbal Pain Scale nvps should be used for intubated patients because a patient that is intubated is unable to speak pain scales such as the FLAC pain scale is used for children question three your patient has a new diagnosis of stroke with a new prescription for Warfarin which of the following will you educate your patient on a increasing foods high in vitamin K like spinach B eating low-fat foods C eating low cholesterol foods D eliminating foods high in vitamin K such as brussels sprouts the correct answer is D eliminating foods high in vitamin K such as brussels sprouts Warfarin prevents blood clotting by interfering with the role that vitamin K plays in a convoluted chain of molecular occurrences however Vitamin K is a substance that is crucial for bone and heart health Warfarin should not be used with vitamin K since it reduces the Drug's efficacy question four your patient is gasping for air which of the following positions are best to place the patient in a trendelenberg b semi-fowlers c High Fowlers D left lateral the correct answer is C High Fowlers High Fowlers is the optimal position for a patient with respiratory distress to be placed in high Fowlers involves the head of the bed chob to be at least 60 degrees up to 90 degrees this position lowers the diaphragm and allows for optimal breathing question five which of the following lung sounds would be most likely heard in a patient with an asthma exacerbation a raunchy B wheezing C stridor D crackles the correct answer is C stridor Strider often denotes a blockage or narrowing of the upper Airway which is external to the chest cavity Strider is often seen in asthma because the airway is swollen and blocked question six you are providing catheter care to a patient with a suprapubic catheter what is the best way to provide catheter care a wash the tubing with soap and water beginning at the catheter bag up to the insertion site of the catheter B using soap and water wash the abdomen around the insertion site C replace the catheter in the abdomen weekly D wash the tubing with soap and water beginning at the insertion site on the abdomen washing away form the site down to toward the drainage bag the correct answer is D wash the tubing with soap and water beginning at the insertion site on the abdomen washing away form the site down to toward the drainage bag cleaning away from the site significantly decreases the risk for infection for the patient the best way to keep infection at its lowest the nurse should start at the site of insertion moving away from the site question seven you are assessing a patient with a new ileostomy you notice that the ostomy is purple which of the following is most likely the issue with the new ileostomy a nothing this is normal since it is outside of the abdomen B the bowel has become ischemic C the stoma has become dry D the stoma the correct answer is B the bowel has become ischemic a stoma for any type of ostomy should be pink slash red and moist if the stoma is purple it has become ischemic and is a medical emergency because the patient can lose that part of their bowel question eight you're caring for a patient with an enteral tube your Physician's orders say to bolus a 450 ml feeding before administering the bolus feed you aspirate 550 ML of gastric fluid which nursing action is most appropriate a administer the bolus feed per MD orders B hold the feed and notify the MD C hold the feet and give in three hours D flush the enteral tube with sterile water and administer bolus feed the correct answer is B hold the feed and notify the MD when providing enteral feeds to a patient if you aspirate more than 500 mL of gastric fluid it may indicate that the patient is not digesting the feedings sometimes doctors will write specific orders regarding when to hold enteral feedings if the doctor's orders are less than 500 mL the order should always be followed question 9 you're a nurse working in the DHS office in your county you are administering covid-19 vaccines which method will you use to ensure that the vaccine stays in the muscle and does not leak back into the subcutaneous tissue a inject at a 90 degree angle B aspirate before giving the injection and give only if you aspirate blood C leave the needle in the muscle after injection for 10 seconds D use the z-track method when administering the injection the correct answer is D use the z-track method when administering the injection while injecting at a 90 degree angle is correct the question asks what is the best way to ensure that the injection stays in the muscle and does not leak back into the subcutaneous tissue the evidence-based practice proves that the z-track method is the best way to prevent leakage when administering IM injections question 10 you're caring for a patient in an external fixation device what is the most important nursing intervention for this patient a offer High high protein meals B encourage the patient to ambulate often to prevent contractures C assess for excess redness around insertion sites D ensure the patient is in a left lateral position while in bed the correct answer is C assess for excess redness around insertion sites when a patient is in an external fixation device the insertion sites should be assessed often these sites can become infected easily excessive redness pus and or exudate can indicate infection at the insertion sites the patients are usually on bed rest and are in a Supine position question 11 the following are high risks when administering an enema to an older adult except a hypercalcemia b hyperphosphatemia c sepsis D bowel perforation the correct answer is a hypercalcemia as adults age the bowel becomes thinner the older adult is at a much higher risk of bowel perforation and sepsis due to bowel perforation than a younger adult the older adult patient is at a high risk for hyperphosphatemia because enemas such as a Fleet enema have an active ingredient of sodium phosphate older adults are also at a higher risk of hypocalcemia with these types of enemas too the following puts the older adult at a high risk of kidney failure and even death question 12 your patient reports that he has been experiencing loss of vision at night only which vitamin is the patient most likely deficient in a vitamin C B vitamin D C vitamin A D vitamin B12 the correct answer is C vitamin A the lack of vitamin C can cause bruising while the lack of vitamin D may cause cramps vitamin A deficiency will cause a patient to have loss of night vision lastly a deficiency in vitamin B12 can cause weakness and tiredness and ultimately tingling in the hands and feet if left untreated question 13 a nurse is instructing parents on how to instill ear drops for their eight-month-old son which of the following statements by the parents would indicate understanding by the parents a pull the pinna upward and back while instilling the drops B lay him on his side and instill the drops quickly see sit him up turn his head and instill the drop slowly D pull the pinna downward and back while instilling the drops the correct answer is D pull the pinna downward and back while instilling the drops the pinna of a child under the age of three should be pulled down and back while instilling drops after the age of three the pinna of the ear should be pulled upward and back to instill drops question 14 the nurse is preparing to remove a Foley catheter before pulling the catheter out what is the most important step a assess the size of the catheter B tell the patient to take a deep breath out C assess for balloon size d remove 10 CC from the balloon the correct answer is C assess for balloon size it is important to assess the size of the balloon because balloon sizes vary if the balloon size is 30 cc and the nurse withdraws 10 CC the balloon will still be somewhat inflated and the removal of the catheter may cause significant trauma to the urethra of the patient question 15 you are a new nurse assessing a patient with a HGB of 6.5 and a 22 gauge peripheral IV the doctor has ordered prbcs to be administered to the patient what is your most important intervention for this patient a given antihistamine before Administration B ensure the patient is warm before Administration C place a peripheral IV that is at least 20 gauge D ensure the patient is on oxygen before Administration the correct answer is C place a peripheral IV that is at least 20 gauge in order to give blood products the patient must have at least a 20 gauge peripheral IV this is because an IV catheter that is smaller than 20 gauge can damage the blood cells while being administered to the patient question 16 what is the proper way to assess an apical pulse on an adult patient a listen at the fifth left intercostal space midclavicular line for 30 seconds and multiply by two B listen at the fourth left intercostal space mid-clavicular line for a full 60 seconds C listen at the fourth left intercostal space midclavicular line for 30 seconds and multiply by two D listen at the fifth left intercostal space midclavicular line for a full 60 seconds the correct answer is D listen at the fifth left intercostal space midclavicular line for a full 60 seconds the correct way to assess an apical pulse on the adult is to listen with a stethoscope at the fifth left intercostal space mid-clavicular line for a full 60 seconds the apical pulse should not be listened to for less than 60 seconds question 17 you're educating a patient with a newly placed plaster cast to her left arm after sustaining a wrist fracture which of the following is the most important thing to educate the patient on a reporting blue fingers immediately B keeping the arm in the sling provided C do not stick anything in the cast to scratch the skin D reporting fever immediately the correct answer is a reporting blue fingers immediately blue slash purple slash gray fingers May indicate lack of oxygen if the fingers become ischemic it becomes a medical emergency so that the patient does not lose their fingers question 18. the nurse in a long-term care facility is assessing a pressure ulcer on a resident the pressure ulcer is red firm sore and has intact skin which of the following stages is the pressure ulcer at a stage 2 B stage 3 C stage the four d stage one the correct answer is D Stage 1 a stage eye pressure ulcer is red and firm may be sore but still has intact skin once the skin breaks the pressure ulcer becomes a stage two ulcer question 19 after a hysterectomy the patient is prescribed a clear liquid diet which of the following is allowed for the diet prescribed a almond milk B orange juice with pulp C Diet Coke D chicken noodle soup the correct answer is C Diet Coke no type of milk is allowed on a clear liquid diet fruit juices without pulp are okay if the chicken noodle soup was strained and only the broth was served this would be okay however the noodles make the soup unavailable for this diet diet sodas are permitted on the clear liquid diet question 20 you are caring for a patient with a newly placed Salem sump that the doctor has ordered to be put on low intermittent suction Lis what is the most accurate intervention to ensure that the Salem sump is in the stomach a instill a 10 mL air bolus while listening to the stomach with your stethoscope B obtaining an abdominal x-ray C pH tests D assessing the patient for respiratory distress the correct answer is B obtaining an abdominal x-ray obtaining an abdominal x-ray is the most accurate way to determine if a feed tube is in the stomach even if a patient is not in respiratory distress the tube may still not be in the stomach question 21 the nurse is caring for a post-hysterectomy patient with a Jackson Pratt drain the drain has approximately 30 cc of dark red drainage which of the following will the nurse document the drainage as a serosanguinous b sanguineous c purulent d Cirrus the correct answer is b sanguineous sanguineous means red drainage serous anguinous means that the drainage is both clear and red purulent indicates white and or yellow drainage that indicates infection Cirrus means clear drainage question 22. the home health nurse is assessing a patient's knee bandage the patient had a knee replacement five days ago the nurse notices dark yellow thick drainage on the bandage how would the nurse document the drainage a cirrus B foul c purulent d unpleasant the correct answer is C purulent the best way to document this type of drainage is purulent purulent means white and slash or yellow drainage that indicates infection question 23 the nurse is caring for a patient with Advanced Alzheimer's disease that has recently begun having trouble swallowing which of the following interventions may be most appropriate for this patient a offer a mechanical soft diet B suggest a feeding tube be placed C suggest sitting the patient in a low Fowler's position when eating D suggest the chin tuck method when the patient is eating the correct answer is a offer a mechanical soft diet when caring for patients the least invasive intervention should be used first suggesting a feeding tube is more invasive than offering a mechanical soft diet the patient with swallowing difficulties should be placed in a high Fowler's position while the chin tuck method can be used for a patient with swallowing difficulties the best intervention would be offering a mechanical soft diet mechanical soft foods may include something like mashed potatoes question 24 which of the following patients best fits the need for an alternating overlay mattress a a 300 pounds patient who is not incontinent b a 150 pounds patient who is incontinent and can reposition herself in bed c a 450 pounds patient who is incontinent of bowel with a stage IV pressure ulcer and cannot reposition himself in bed d a 245 pounds patient who is incontinent of bladder with a stage 2 pressure ulcer and cannot reposition herself in bed the correct answer is d a 245 pounds patient who is incontinent of bladder with a stage 2 pressure ulcer and cannot reposition herself in bed and alternating overlay mattress is best used for patients 250 pounds and under a low air loss bed would be the most ideal however the low air loss beds are very expensive the overlay mattress is also liquid resistant for patients who are incontinent of bladder question 25 a resident's daughter reports to you the nurse that her mother with late stage dementia has recently started declining all food brought to her what is your best advice for the daughter a offer residents favorite foods B let the resident get really hungry and offer her food C give the resident more time at meals D offer extra liquids to ensure proper calorie intake the correct answer is a offer residents favorite foods it is not okay to ever let a patient go hungry using the method they will eat when they are hungry is unethical when caring for patients giving the patient with dementia extra time to eat is unlikely to encourage the patient with dementia to eat liquid should not be the biggest source of calorie intake the best intervention is to offer the residents favorite foods to encourage the patient to eat question 26 what is the evidence-based practice logic behind placing anti-embolism stockings before the patient gets out of bed in the morning a patients are more prone to embolisms in the morning after being in bed all night B to keep fluid and blood from pooling in the ankles calves and feet before placement C they can keep the patient from falling D they can keep the patient form having pain in their legs upon ambulation the correct answer is B to keep fluid and blood from pooling in the ankles calves and feet before placement the logic behind anti-embolism stockings is to compress the legs before the patient stands to ensure that blood does not pool in the ankles calves or feet if blood pools in these areas the patient is at a very high risk of forming a blood clot question 27 your patient is on a pescetarian diet which of the following should not be included on the patient's lunch tray a eggs B milk C fish D beef the correct answer is D beef pescetarianism is the practice of including Seafood in a diet that is primarily vegetarian other animal items such as eggs and dairy are optional for pescetarians question 28 which of the following identifies oliguria a 250cc urine in 24 hours B 1500 CC urine in 24 hours C 3000 CC urine in 24 hours D 400c urine in 24 hours the correct answer is d 400c urine in 24 hours less than 400 cc of urine in 24 hours is classified as oliguria there are causes of low urine production besides underlying illnesses dehydration retaining urine and adverse drug reactions are a few examples question 29 you are caring for a patient who recently had a stroke the patient is experiencing residual Aphasia due to the stroke which of the following is most important to Aid in communication for the patient a weighted utensils B ambulating devices C communication boards D thickener for fluids to prevent aspiration the correct answer is C communication boards communication boards are wonderful aids for communication for patients who have had a recent stroke Aphasia is the inability to speak or understand what is being spoken the only device that aids this patient with communication is a communication board question 30 you are administering medications to a patient who is on amlodipine Norvasc which of the following supplements would you not give with amlodipine a vitamin D B vitamin C C magnesium D calcium the correct answer is C magnesium magnesium can cause the blood pressure to drop too low adding magnesium to other blood pressure medications can exacerbate the decrease of blood pressure question 31 a nurse is educating a patient about his new diagnosis of ESRD end-stage renal disease which of the following is the most important to educate the patient on limiting in his diet a calcium b majinium c sodium D potassium the correct answer is C sodium consuming more sodium raises the intravascular blood volume blood pressure and ultimately the pressure in the glomeruli renal function is reduced as a result of the overall impact a renal patient should limit their sodium intake to 2 2000 milligrams daily one teaspoon is equivalent to 2 300 milligrams of sodium this means that a renal patient should consume less than one teaspoon of sodium daily question 32 the nurse is caring for an 87 year old new home health patient who has had an extended stay in the hospital after a fall that led to a broken hip that required a hip replacement followed by hospital-acquired pneumonia which of the following is most important for the nurse to educate the family on a ensure the patient's oxygen cord reaches to her bathroom B remove all throw rugs in the home C ensure the patient performs her breathing exercises daily D ensure the patient takes all medications as prescribed the correct answer is B remove all throw rugs in the home the number one thing to remember is the patient's safety while all the other options are good to remember for this patient we should focus on why she was in the hospital to begin with it was Falls removing the throw rugs in the home is the best intervention to prevent Falls for this patient question 33 you're caring for a patient who was recently diagnosed with terminal cancer he tells you that he wants to ensure that all of his wishes are met as his condition worsens which of the following will be best to suggest to the patient to ensure his wishes are met a a will be a power of attorney POA C A DNR do not resuscitate D and advance directive the correct answer is D an advance directive a living will usually referred to as an advance directive is a legal instrument that specifies a client's preferred standards of care if a client is unable to make medical choices for himself a medical power of attorney can DNR orders which stand for do not resuscitate only block the advancement to some life-saving interventions and do not guide medical decision making the distribution of assets and the care of dependents in the case of a client's passing are the main concerns of standard Wills question 34 a nurse is caring for a patient who has been bedridden for seven days which of the following is the most important intervention for the nurse to perform a have the patient dangle his feet while sitting for several seconds before having the patient stand B place the patient's Walker close to the bed for easy reach C ask the patient what his pain level is D explain to the patient how far he must walk the correct answer is a have the patient dangle his feet while sitting for several seconds before having the patient stand this patient has been bedridden for seven days therefore they are at high risk for orthostatic hypertension to offset orthostatic hypertension the nurse should have the patient sit on the side of the bed and dangle their feet before standing question 35 you're caring for a 21 year old patient with Down Syndrome who is non-verbal which of the following pain scales would be most appropriate to use on this patient a cries B numeric C Peak rest D faces the correct answer is D faces the pqrst Pain Scale entails looking into any precipitating events the characteristics of the pain its area and location its severity and its time and triggers it offers a comprehensive evaluation of the pain and is suitable for use in the adult population it is advisable to use the flay C and cries scales on newborns and young children faces may be used with people of any age although it works best with kids and teenagers question 36 the nurse is caring for a resident in a long-term care facility who often experiences nighttime agitation which of the following would best benefit the resident a allow the patient to take several naps during the day to catch up on sleep B encourage the family to visit the resident for most of the day to keep the resident awake C ensure the resident stays up in his wheelchair for most of the day D schedule multiple activities during the day for the resident the correct answer is D schedule multiple activities during the day for the resident this patient needs help sleeping at a normal bedtime instead of being agitated all night scheduling activities for the patient to do will help keep the patient on a schedule and keep the patient from sleeping during the day it is not okay to keep the patient in his wheelchair all day because he may get a decubitus on his sacrum further he may still fall asleep in his wheelchair question 37 the nurse is caring for a patient who recently suffered a stroke The Physician orders for the patient to be Advanced to a clear liquid diet from NPO before allowing the patient to drink which of the following Healthcare team members should assess the patient a The Physician B speech pathologist c a dietitian D an ENT Physician the correct answer is B speech pathologist the client's capacity to chew and swallow might be evaluated by speech therapists before increasing their diet patients with dysphagia should have a thorough swallow examination especially if it is caused by a stroke or brain hemorrhage additional treatments and therapy would be necessary if clients were observed to exhibit aspiration or choking Tendencies during swallowing question 38 which of the following diets should a patient with Cushing's Disease adhere to a low-fat low protein low sodium B high fat low protein low sodium C high sodium low protein low fat D low-fat high protein low sodium the correct answer is D low-fat high protein low sodium a patient with Cushing's Disease should follow a low-fat high protein and low sodium diet Cushing syndrome-related excess cortisol can raise blood pressure and cause hypertension avoid processed foods that are heavy in salt since they might raise blood pressure try to restrict meals that might raise blood sugar levels as Cushing syndrome can result in high blood glucose levels reduced bone density or osteoporosis may result from Cushing's Disease for those with Cushing's disease doctors advise a balanced diet rich in calcium and vitamin D since these nutrients build bones high cholesterol is a typical Cushing symptom therefore foods low in fat are necessary high protein diets can stop muscles from withering away question 39 which of the following is best for the patient with gout to eat a baked chicken B pasta with creamy pesto sauce C hamburger D turkey sandwich the correct answer is B pasta with creamy pesto sauce alcohol and foods high in purine uric acid which include the majority of protein-rich diets should be avoided by gout patients the only option that is not protein Rich here is option b question 40 the nurse is educating a patient upon discharge the patient was recently diagnosed with Addison's disease which of the following will the nurse not instruct the patient to avoid a potassium B calcium C sodium D magnesium the correct answer is C sodium normal dietary salt is necessary for an Addison's disease adrenal insufficiency patient to maintain electrolyte balance and prevent excessive fluid loss in the event that Addison's disease is diagnosed the patient shouldn't abstain from Salt thank you for watching this video we hope you enjoyed it click the first link in the description to take the free NCLEX practice test also check out these videos that can help you with your future studies don't forget to resuscitate the like button and subscribe to our Channel and please share this video with your fellow nursing friends

Channel: All Healthcare Careers

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Keywords: basic care and comfort questions, basic care and comfort nclex questions, nclex basic care and comfort questions, basic care and comfort nclex rn questions, basic care and comfort nclex rn, basic care and comfort nclex practice test answers, basic care and comfort nclex practice test answer key

Id: IQI6hxG4ZM8

Length: 29min 53sec (1793 seconds)

Published: Wed May 31 2023