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NCLEX RN· Basic Care and Comfort · RN Nursing Basic Care and Comfort

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Showing all 3 practice questions with expert explanatory rationales.

Question 1 of 3

The nurse is assessing a six-month-old infant at the clinic. When the nurse strokes from the heel of the foot upward toward the ball, the infant exhibits no movement. Which action is the priority for the nurse?

A. take the infant's vital signs

B. order a neurology consult

C. examine the infant's nose and ears

D. ask how much formula the infant consumes daily

Expert Explanatory Rationale

Correct Answer: order a neurology consult

Question 2 of 3

The nurse is caring for a group of clients in a medical/surgical unit. Which client does the nurse understand to be at highest risk for developing decubitus ulcers?

A. a 27-year-old client who fractured her arm playing volleyball

B. a 6-year-old client on pelvic skin traction for muscle spasms

C. a 42-year-old obese client with controlled atrial fibrillation who uses a wheelchair

D. a 70-year-old client with heart failure who uses a cane for ambulation in the room and hall

Expert Explanatory Rationale

Correct Answer: a 42-year-old obese client with controlled atrial fibrillation who uses a wheelchair

Question 3 of 3

The nurse is caring for a client with fluid overload who is on strict I's and O's. The nurse understands that which is the best way to ensure accurate I's and O's?

A. clear any IV pumps and reset to zero for accurate IV fluid intake

B. ask the client to keep up with how many cups of fluid he drinks at meals

C. ask the client to report how much urine is in the urinal each time he uses it

D. tell the client not to ask for any extra water or drinks that are not on the meal tray

Expert Explanatory Rationale

Correct Answer: clear any IV pumps and reset to zero for accurate IV fluid intake

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