Q&A Basic Care and Comfort

Results for Lesson 5: Basic Care and Comfort Questions are numbered by the order in which they appeared in the test. Represents the correct answer. Question 1 The nurse has been teaching a client with congestive heart failure about proper nutrition. Which of these lunch selections indicates the client has learned about sodium restriction?

A) Cheese sandwich with a glass of 2% milk

B) Sliced turkey sandwich and canned pineappleC) Cheeseburger and baked potatoD) Mushroom pizza and ice cream

Answers Correct B Student's D

Review Information: The correct answer is B: Sliced turkey sandwich and canned pineappleSliced turkey sandwich is appropriate since it is not a highly processed food and canned fruits are low in sodium. All of the other choices contain one or more high-sodium foods.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Lutz, C.A. and Prytulski, K.R. (2001). Nutrition and diet therapy. (3rd edition). Philadelphia: F.A. Davis Company.

Question 2 When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula

A) every four to six hours

B) continuouslyC) in a bolusD) every hour

Answers Correct B Student's B

Review Information: The correct answer is B: continuouslyUsually gastrostomy and jejunostomy feedings are given continuously to ensure proper absorption. However, initial feedings may be given by bolus to assess the client''s tolerance to formula.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing:

Assessment & management of clinical problems. St. Louis: Mosby.


Question 3 A client with diarrhea should avoid which of the following?

A) orange juice

B) tunaC) eggsD) macaroni

Answers Correct A Student's A

Review Information: The correct answer is A: orange juiceOrange juice is contraindicated for a client with diarrhea because it increases the motility of the gastrointestinal tract.

Beare, P. and Myers, J. (1998). Adult Health Nursing. (3rd Edition). St. Louis, Missouri: Mosby.


Question 4 The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs?

A) three apricots

B) medium bananaC) naval orangeD) baked potato

Answers Correct D Student's A

Review Information: The correct answer is D: baked potatoA baked potato contains 610 milligrams of potassium.

Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.


Question 5 A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for


development of decubitus ulcers?

A) A 79 year-old malnourished client on bed rest

B) An obese client who uses a wheelchairC) An incontinent client who has had 3 diarrhea stoolsD) An 80 year-old ambulatory diabetic client

Review Information: The correct answer is A: A 79 year-old malnourished client on bed restWeighing significantly less than ideal body weight increases the number and surface area of bony prominences which are susceptible to pressure ulcers. Thus, malnutrition is a major risk factor for decubiti, due in part to poor hydration and inadequate protein intake.

Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders.


Question 6 The nurse is teaching an 87 year-old client methods for maintaining regular bowel movements. The nurse would caution the client to avoid

A) glycerine suppositories

B) fiber supplementsC) laxativesD) stool softeners

Answers Correct C Student's A

Review Information: The correct answer is C: laxativesSome elders are constipated because they have used over-the-counter laxatives for a long time. In addition, many people do not eat enough fiber, drink enough water, or exercise adequately. Certain medications, including opioid analgesics, are constipating. Elders are rarely constipated because of organic or pathological reasons.

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby.


Question 7 The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate?

A) Decreased carbohydrates and fat

B) Decreased sodium and potassium


C) Increased potassium and proteinD) Increased sodium and fluids

Review Information: The correct answer is B: Decreased sodium and potassiumChildren with AGN who have edema, hypertension oliguria, and azotemia have dietary restrictions limiting sodium, potassium, fluids, and protein.

McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Question 8 A nurse is working with a client in an extended care facility. Which bed position is preferred for a client, who is at risk for falls, as part of a prevention protocol?

A) All 4 side rails up, wheels locked, bed closest to door

B) Lower side rails up, bed facing doorway

C) Knees bent, head slightly elevated, bed in lowest position

D) Bed in lowest position, wheels locked, place bed against wall

Answers Correct D Student's D

Review Information: The correct answer is D: Bed in lowest position, wheels locked, place bed against wallIt is no longer advisable to use only the lower side rails. Using all 4 side rails (upper and lower siderails at the top and bottom of the bed) is an inappropriate use of restraint without an order. If all 4 are pulled up, an order for protective restraints is needed that usually has to be renewed in 48 to 72 hours along with more frequent documentation. Having all 4 side rails raised limits the client’s autonomy and freedom of movement. Using 3 of the 4 side rails pulled up is acceptable, because clients can safely exit the bed on their own initiative. Placing the bed against the wall permits getting out of bed on only 1 side. Locking the wheels keeps the bed from sliding. Keeping the bed in the lowest position (without bending limbs to restrict movement) provides a shorter distance to the ground if the client chooses to get out of bed.


Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

Question 9 A client is being maintained on heparin therapy for deep vein thrombosis (DVT). The nurse must closely monitor which of the following laboratory values?

A) bleeding time

Answers Correct C Student's C

B) platelet countC) activated PTTD) clotting time

Review Information: The correct answer is C: activated PTTHeparin is used to prevent further clots from being formed and to prevent the present clot from enlarging. The Activated Prothromboplastin Time (APTT) test is a highly sensitive test to monitor the client on heparin.

Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA: Thompson Delmar Learning.

Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Question 10 Which statement best describes the effects of immobility in children?

A) Immobility prevents the progression of language and fine motor development

B) Immobility in children has similar physical effects to those found in adults

C) Children are more susceptible to the effects of immobility than are adults

D) Children are likely to have prolonged immobility with subsequent complications

Answers Correct B Student's A

Review Information: The correct answer is B: Immobility in children has similar physical effects to those found in adultsCare of the immobile child includes efforts to prevent complications of muscle atrophy, contractures, skin breakdown, decreased metabolism and bone demineralization. Secondary alterations also occur in the cardiovascular, respiratory and renal systems. Similar effects and alterations occur in adults.

Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders.

Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Question 11 An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse should be

A) assess the severity and location of the pain

B) obtain an order for an analgesicC) reassure him that this is not unusual for his ageD) encourage him to increase his activity


Review Information: The correct answer is A: assess the severity and location of the

painMost older adults have 1 or more chronic painful illnesses, and in fact, they often must be asked about discomfort (rather than "pain") to reveal the presence of pain. There is no evidence that pain of older adults is less intense than younger adults. It is important for the nurse to assess the pain thoroughly before implementing pain relief measures.

Estes, M.E.Z. (2002). Health Assessment and Physical Examination, (2nd Ed). Albany, NY: Delmar.


Question 12 After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is

A) abdominal x-ray

B) auscultationC) flushing tube with salineD) aspiration for gastric contents


Review Information: The correct answer is A: abdominal x-rayPlacement should be verified by radiograph to determine that the tube is in the stomach or intestine rather than in the airways.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.


Question 13 Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse's priority?

A) obtain a complete blood count

B) obtain a health and dietary historyC) refer to a provider for a physical examinationD) measure height and weight


Review Information: The correct answer is B: obtain a health and dietary historyInitially, the nurse should obtain information about the chronicity of and details about constipation, recent changes in bowel habits, physical and emotional health, medications, activity pattern, and food and fluid history. This information may suggest causes as well as an appropriate, safe treatment plan.

Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan.

(5th edition). St. Louis, Missouri: Mosby.


Question 14 After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate to suggest?

A) 3 oz. broiled fish, 1 baked potato, ½ cup canned beets, 1 orange, and milk

B) 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple

C) A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice

D) 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange

Answers Correct D Student's D

Review Information: The correct answer is D: 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orangeCanned fish and vegetables and cured meats are high in sodium. This meal does not contain any canned fish and/or vegetables or cured meats.



Question 15 A client in a long term care facility complains of pain. The nurse collects data about the client’s pain. The first step in pain assessment is for the nurse to

A) have the client identify coping methods

B) get the description of the location and intensity of the pain

C) accept the client’s report of painD) determine the client’s status of pain


Review Information: The correct answer is C: accept the client’s report of painAlthough all of the options above are correct, the first and most important piece of information in this client’s pain assessment is what the client is telling you about the pain --“the client’s report.”

Price, S.A. and Wilson, L.M. (2003). Pathophysiology clinical concepts of disease

processes. (6th edition). Mosby: St. Louis, Missouri.


Question 16 What finding of the nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?

A) Presence of blood in stools

B) Oozing liquid stoolC) Continuous rumbling flatulenceD) Absence of bowel movements


Review Information: The correct answer is B: Oozing liquid stoolWhen the bowel is impacted with hardened feces, there is often a seepage of liquid feces around the obstruction. This is often mistaken for uncontrolled diarrhea.



Question 17 A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?

A) Allow the client to melt ice chips in the mouth

B) Provide mints to freshen the breathC) Perform frequent oral care with a tooth spongeD) Swab the mouth with glycerin swabs


Review Information: The correct answer is C: Perform frequent oral care with a tooth spongeFrequent cleansing and stimulation of the mucous membrane is important for a client with a nasogastric tube to prevent development of lesions and to promote comfort. Ice chips or mints could be contraindicated, and do not stimulate the tissue. Glycerin swabs do not cleanse since they only moisturize.


Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

Question 18 An 86 year-old nursing home resident who has impaired mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?

A) Add a thickening agent to the fluids

B) Check the client’s gag reflexC) Feed the client only solid foodsD) Increase the rate of intravenous fluids

Answers Correct B Student's A

Review Information: The correct answer is B: Check the client’s gag reflexWhen a new problem emerges, the nurse should perform appropriate assessment so that suitable nursing interventions can be planned. Aspiration pneumonia follows aspiration of material from the mouth into the trachea and finally the lung. A loss or an impairment of the protective cough reflex can result in aspiration.



Question 19 The nurse is planning care for a client with a cerebral vascular accident (CVA). Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?

A) Place client in the wheelchair for four hours each day

B) Pad the bony prominenceC) Reposition every two hoursD) Massage reddened bony prominence


Review Information: The correct answer is C: Reposition every two hoursClients who are at risk for skin breakdown develop fewer pressure ulcers when turned every two hours. By relieving the pressure over bony prominences at frequent scheduled intervals, blood flow to areas of potential injury is maintained.



Question 20 The nurse is instructing a 65 year-old female client Answers Correct A

diagnosed with osteoporosis. The most important instruction regarding exercise would be to

A) exercise doing weight bearing activities

B) exercise to reduce weight

C) avoid exercise activities that increase the risk of fracture

D) exercise to strengthen muscles and thereby protect bones

Student's A

Review Information: The correct answer is A: exercise doing weight bearing activitiesWeight bearing exercises are beneficial in the treatment of osteoporosis. Although loss of bone cannot be substantially reversed, further loss can be greatly reduced if the client includes weight bearing exercises along with estrogen replacement and calcium supplements in their treatment protocol.



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Q&A Basic Care and Comfort