Question 1

The nurse is teaching a client with low back pain. Which of the following statements, if made by the client, would require follow-up?

Accepted Answer

Answer reason: " For low back pain, recommended positioning aims to maintain a neutral spine and reduce lumbar lordosis and muscle strain. Prone sleeping tends to increase lumbar extension and can worsen back pain, so it indicates misunderstanding and needs follow-up teaching. More supportive positions include side-lying with knees flexed and a pillow between the knees, or supine with a pillow under the knees. Proper lifting mechanics (using the legs) and other health behavior changes can help reduce strain and improve outcomes, making them appropriate statements.

Question 2

According to traditional Chinese medicine, what is defined as the vital energy of the human body?

Accepted Answer

Answer reason: Traditional Chinese medicine describes health as the balanced flow of vital life energy throughout the body. That vital energy is termed qi, which is thought to circulate and influence physical and emotional well-being. Meridians are the pathways through which this energy is believed to travel, and acupoints are specific sites used to access those pathways. Yin and yang refer to complementary forces whose balance is believed to support normal function, not the name of the energy itself.

Question 3

A client on complete bed rest complains of excessive flatulence. What is the best position for the nurse to place the client in?

Accepted Answer

Answer reason: The knee-chest position increases intra-abdominal pressure and helps move trapped gas through the colon and rectum, often providing faster relief for a bedrest client. Upright positions like Fowler’s or Semi-Fowler’s may aid general comfort but are less targeted for mobilizing flatus. Trendelenburg’s can increase abdominal pressure against the diaphragm and is not used to relieve intestinal gas discomfort.

Question 4

A client is admitted with deep vein thrombosis (DVT). Which of the following interventions would be most appropriate to relieve the pain?

Accepted Answer

Answer reason: Elevating the affected extremity promotes venous return via gravity, reduces swelling, and thereby decreases discomfort. Exercise is inappropriate in acute DVT because increased muscle pumping can dislodge part of the clot and precipitate embolization. Heat may be used cautiously in some settings, but elevation is the most direct, standard nonpharmacologic measure to reduce venous pooling and pain.

Question 5

Which of the following positions would the nurse assist a client to assume for the relief of pain experienced with appendicitis?

Accepted Answer

Answer reason: Flexing the hips and knees decreases abdominal wall strain and reduces peritoneal irritation, which can ease right lower quadrant discomfort. Positions that extend the abdomen (such as supine stretched out) typically increase pain by increasing traction on inflamed tissues. This nursing action is a nonpharmacologic comfort measure that supports symptom relief while further evaluation and treatment occur.

Question 6

Which of the following nursing diagnoses would the nurse select as a priority for this client?

Accepted Answer

Answer reason: Musculoskeletal disorders commonly produce significant pain that can limit mobility, impair participation in care, and drive stress responses (tachycardia, hypertension), making prompt assessment and treatment a priority nursing focus. Managing pain also supports safer movement, better pulmonary hygiene, and improved sleep, so it has downstream benefits compared with addressing sleep disturbance first. Infection prevention is important, but without cues of an active infection or high-risk invasive situation, it is usually secondary to treating the current, evident problem. Ineffective coping is addressed after stabilizing and relieving pressing physiologic distress.

Question 7

Which type of therapy uses substances found in nature?

Accepted Answer

Answer reason: Biologically based complementary therapies use naturally occurring substances such as herbs, vitamins, minerals, probiotics, and other dietary supplements. This directly matches the question’s focus on “substances found in nature,” which are taken or applied for health-related effects. In contrast, mind-body interventions target mental processes (e.g., meditation), and body-based methods involve physical manipulation (e.g., massage) rather than ingestible or natural products. Energy therapies focus on manipulating energy fields, not using natural substances.

Question 8

Which outcome is a goal of cognitive behavioral pain intervention?

Accepted Answer

Answer reason: Cognitive-behavioral pain interventions aim to modify maladaptive thoughts, beliefs, and coping behaviors that amplify the pain experience. By reframing interpretations and improving coping skills (e.g., relaxation, distraction, cognitive restructuring), the patient can reduce distress and perceived pain intensity and improve function. Direct “pain relief” is not the primary mechanism, and correcting physical dysfunction is addressed by physical/rehabilitative therapies rather than CBT. While reducing fear of movement can be a CBT-related target, the broad, central goal is altering the cognitive appraisal/perception of pain.

Question 9

Which treatment for paronychia would be the most appropriate?

Accepted Answer

Answer reason: Paronychia is a localized soft-tissue infection/inflammation of the nail fold, and initial conservative management aims to reduce pain and swelling while promoting drainage. Warm soaks increase local circulation and can help an early or mild infection resolve and/or allow spontaneous drainage before escalation. Ice and splinting are more appropriate for traumatic injuries and may reduce perfusion needed for healing. Observation alone risks progression to abscess, and routine hospital admission for IV antibiotics is unnecessary unless there are systemic signs, spreading cellulitis, immunocompromise, or failure of outpatient therapy.

Question 10

A nurse is explaining treatments to the parents of a child with hypertrophic scarring. Which method would be the best for controlling this condition?

Accepted Answer

Answer reason: Pressure therapy is a standard, first-line noninvasive approach in children with hypertrophic scarring, especially after burns, and is most effective when worn consistently over time. Moisturizers can decrease dryness and itching but do not reliably control scar overgrowth. Splints and physiotherapy are important to prevent contractures and preserve function, but they target range of motion rather than directly reducing hypertrophic scar formation.

Question 11

The nurse is assessing pain in a 3-year-old client after surgery. Which pain scale should the nurse use to assess this client’s pain level?

Accepted Answer

Answer reason: Preschool children often cannot reliably quantify pain on a numeric or visual analog scale due to limited abstract thinking and number concepts. A faces-based scale matches their developmental level by allowing them to choose a picture that best represents how they feel. This supports more accurate, consistent assessment and reassessment of postoperative pain. Numeric and visual analog tools are better suited to older children who can understand ranking and proportional distances, making them less appropriate here.

Question 12

Pain control is an important aspect of client care. Which theory most accurately addresses a client’s pain?

Accepted Answer

Answer reason: Pain perception is modulated at the spinal cord level, where competing sensory input can inhibit transmission of nociceptive signals to the brain. explains why interventions like massage, heat/cold, repositioning, and TENS can reduce perceived pain by “closing the gate” to pain impulses. It best aligns with nursing pain management because it supports both pharmacologic and nonpharmacologic strategies and the subjective nature of pain. The other options are not recognized, standard pain theories used in nursing practice and do not provide a coherent mechanism for clinical pain modulation.

Question 13

Which technique is appropriate for promoting proper breathing in a client experiencing pain or anxiety?

Accepted Answer

Answer reason: Inhaling through the nose encourages diaphragmatic breathing and humidifies/warms air, supporting smoother, more efficient ventilation. Exhaling through the mouth can be paced (e.g., longer exhale than inhale), which promotes relaxation and decreases air trapping. Rapid breathing patterns in either shallow or deep form can worsen dizziness, hypocapnia, and anxiety, making them poor choices here.

Question 14

A client has an inflamed area on the right forearm that’s causing considerable discomfort. The nurse would anticipate the physician to prescribe which measure?

Accepted Answer

Answer reason: Gentle warmth and moisture can soothe inflamed tissue, decrease pain, and help mobilize inflammatory exudate without adding pressure or friction. An elastic bandage can increase irritation or impair circulation if swelling is present, and a nonadherent dressing is mainly for open or draining lesions rather than simple inflammation. Topical corticosteroid may be appropriate for specific inflammatory dermatoses (e.g., contact dermatitis), but the broad, safest anticipated measure for an inflamed painful area is warm, moist compresses.

Question 15

Which nursing intervention should be done postoperatively for a neonate after the repair of a tracheoesophageal fistula and esophageal atresia?

Accepted Answer

Answer reason: Neonates after TEF/EA repair are typically kept NPO with an OG/NG tube for esophageal decompression, so they need safe non-nutritive soothing. Frequent pacifier use provides comfort, supports self-regulation, and helps meet the infant’s strong sucking need without stressing the surgical site or risking aspiration from oral feeding. Mouth care should not be withheld because oral secretions can accumulate and contribute to irritation and infection risk. Routine restraints are not a standard comfort measure and can increase stress; protection of the repair is better achieved with positioning, careful line/tube management, and appropriate sedation/analgesia as ordered.

Question 16

What is the best definition of palliative care?

Accepted Answer

Answer reason: Palliative care is guided by the principle of optimizing quality of life by preventing and relieving suffering through symptom control and support. It is appropriate when cure is not achievable or is no longer the goal, and it focuses on managing pain, dyspnea, nausea, anxiety, and other burdensome symptoms while supporting the client and family. This option best captures the shift from curative intent to symptom-focused management. A common distractor is equating palliative care only with end-of-life or terminal care; hospice is a subset of palliative care, but palliative care itself is broader than terminal-only care.

Question 17

Which list contains common symptoms of terminally ill clients?

Accepted Answer

Answer reason: Terminal illness commonly produces multisystem symptom burden from disease progression and reduced physiologic reserve, especially pain/discomfort, dyspnea, nausea, and profound fatigue. This option lists hallmark end-of-life symptoms that drive nursing comfort measures such as positioning, oxygen/airflow, antiemetics, and energy conservation. Options that include “effective breathing” and “adequate nutrition” describe stable function rather than typical decline near end of life. Choices emphasizing hunger/diarrhea or urinary continence are less characteristic than dyspnea and generalized weakness in terminally ill clients.

Question 18

The home health nurse is instructing the mother of a child diagnosed with juvenile rheumatoid arthritis (JRA) on interventions to reduce the child's pain and stiffness. What is the most appropriate intervention?

Accepted Answer

Answer reason: A warm bath provides gentle, even moist heat over multiple joints and is practical and safe for home use, especially before activity or range-of-motion exercises. Cold therapy is more useful for acute swelling after exertion and may worsen stiffness when used as the primary strategy. Alternating heat and cold is not the usual first-choice comfort measure for baseline JRA stiffness and can be harder to apply consistently and safely at home.

Question 19

A pediatric nurse is caring for a 4-week-old neonate with severe colic. Which assessment finding does the nurse interpret as a sign of acute pain?

Accepted Answer

Answer reason: A sudden wide-eyed, startled facial expression reflects increased arousal and distress commonly associated with pain episodes such as severe colic. Whimpering can occur with many forms of discomfort or need (eg, wet diaper, fatigue) and is less specific for acute pain than a marked facial/alertness change. Limp posture is more consistent with decreased tone or fatigue/illness rather than the typical vigorous, tense response seen with pain. Wanting to breastfeed frequently is more suggestive of hunger or using feeding as a soothing behavior, not a direct indicator of acute pain.

Question 20

Which client should a nurse place in an orthopneic position?

Accepted Answer

Answer reason: A client reporting dyspnea benefits most because elevating the torso decreases diaphragmatic pressure from abdominal contents and can reduce pulmonary congestion-related shortness of breath. Lower-extremity edema is better addressed with leg elevation, not orthopnea. Pressure ulcers and suspected DVT require repositioning/pressure relief and clot-safety measures rather than a breathing-optimized posture.

Question 21

The nurse is caring for the client to manage and decrease the sensation of nausea. Which nonpharma-cological intervention should the nurse recommend?

Accepted Answer

Answer reason: It is simple, low-risk for many patients, and fits nursing comfort-measure recommendations when no contraindications exist. Rapid position changes can worsen nausea by increasing vestibular stimulation and precipitating dizziness. Decreasing solid food is a dietary modification rather than a targeted comfort intervention, and “stimulating” music is more likely to increase sensory input than relieve nausea in many patients.

Question 22

The client has an hordeolum of the left eye, which is painful. Which intervention, if prescribed, should the nurse implement?

Accepted Answer

Answer reason: A hordeolum (stye) is an acute localized eyelid gland infection, and first-line nursing management focuses on comfort and promoting drainage. Warm compresses increase local circulation, soften obstructed secretions, and help the lesion drain, which typically reduces pain and speeds resolution. Patching is generally avoided because it can trap moisture/secretions and may worsen bacterial growth. Miotics are used for glaucoma, not eyelid infections, and IV antibiotics are unnecessary unless there is significant spreading infection (e.g., preseptal/orbital cellulitis) or systemic involvement.

Question 23

The nurse is preparing to perform chest physiotherapy on the child with CF. When should the nurse plan to perform the treatment?

Accepted Answer

Answer reason: Scheduling airway clearance when the stomach is relatively empty improves tolerance and safety. Performing it at least an hour before meals aligns with preventing aspiration and promoting effective participation in airway clearance. Other timing options are either nonsensical in sequence (postural drainage is part of chest physiotherapy) or ignore the key safety priority of avoiding emesis around mealtimes.

Question 24

Following repair of a cleft lip in a 3-month-old infant, the mother asks the nurse what would be the most appropriate toy to bring the infant. What is the best response by the nurse?

Accepted Answer

Answer reason: A visually stimulating toy provides comfort and distraction without encouraging sucking/chewing behaviors that could traumatize the incision. At 3 months, infants engage well with visual tracking, making an overhead mobile developmentally appropriate. A teething ring is a common distractor but promotes oral manipulation and would place direct pressure on the repaired area.

Question 25

The nurse is preparing a treatment plan for a child with sickle cell anemia in vaso-occlusive crisis. What is the most important nursing intervention for the nurse to include?

Accepted Answer

Answer reason: Rapid analgesia (often opioids) paired with comfort measures reduces physiologic stress and improves the child’s ability to participate in other therapies like hydration and oxygen as ordered. Cold exposure can precipitate further sickling via vasoconstriction, so a cool environment is harmful. Fluids should generally be encouraged/maintained to reduce blood viscosity and support perfusion, so restricting fluids is inappropriate, and immobilization may be used for comfort but does not address the primary priority as directly as pain control.

Question 26

The postoperative client who received a spinal anesthetic is experiencing a headache, photophobia, and double vision. What should be the nurse’s initial intervention?

Accepted Answer

Answer reason: The first nursing action is a nonpharmacologic measure that reduces traction on intracranial structures and can decrease symptom severity. Flat bedrest is an appropriate immediate intervention while further evaluation and treatments (e.g., hydration, caffeine, epidural blood patch) are considered. Notifying the surgeon is appropriate if symptoms persist or worsen, but it is not the initial comfort/safety step at the bedside. Limiting fluids is counterproductive, and steroids are not a first-line nursing intervention for this complication.

Question 27

Which client would benefit most from therapeutic touch therapy?

Accepted Answer

Answer reason: Therapeutic touch is a nonpharmacologic comfort measure aimed at reducing anxiety and promoting relaxation, which can also lessen the perception of pain. Pregnancy often limits medication options for minor discomforts, making safe, supportive, noninvasive interventions especially appropriate. This client has two target symptoms—anxiety and musculoskeletal discomfort—that commonly respond to relaxation-based techniques. In contrast, a history of physical abuse can make touch-based interventions distressing unless carefully assessed and consented, and septic shock in the ICU requires urgent physiologic stabilization rather than adjunct comfort therapies.

Question 28

Which is the most accurate statement regarding pain?

Accepted Answer

Answer reason: Pain is highly prevalent across acute and chronic conditions and is a leading reason patients seek medical care, making it a broadly accurate general statement. Pain is complex and multifactorial, with ongoing gaps in understanding mechanisms and best individualized management, so claiming it is “well understood” is too strong. Pain is subjective and influenced by psychological, cultural, and situational factors, so it is not experienced the same way by every client. It can also occur without clear tissue damage (e.g., neuropathic pain, central sensitization, some headache syndromes), so restricting it to physical bodily damage is inaccurate.

Question 29

The nurse wants to promote comfort and relaxation after giving the client a bed bath. Which action best meets this goal?

Accepted Answer

Answer reason: Nonpharmacologic comfort measures that provide direct tactile stimulation can reduce muscle tension, improve circulation, and activate relaxation responses. A back rub is a classic nursing intervention after hygiene care that addresses comfort immediately and can help the client settle for rest. Dimming lights and soft music may support relaxation but are indirect environmental changes and vary more with patient preference. Warm milk and cookies may be inappropriate due to diet restrictions, aspiration risk, or nausea, so it is less universally safe and goal-directed than touch-based comfort care.

Question 30

The nurse is caring for the 5-year-old with rubeola. Which intervention by the nurse best ensures the child’s comfort?

Accepted Answer

Answer reason: Rubeola commonly causes photophobia and significant conjunctival irritation, so minimizing bright light is a direct, noninvasive comfort measure. A darkened, quiet environment reduces eye pain and headache and supports rest during the acute phase. Oil baths are not a priority comfort intervention and can irritate skin or add slip risk, while mist tents are outdated and can increase infection risk without clear benefit. Decongestants are generally not recommended for young children due to limited benefit and potential adverse effects, making them a poorer comfort choice.

Question 31

The adolescent diagnosed with hepatitis is reporting pruritus. Which therapy should the nurse suggest?

Accepted Answer

Answer reason: Pruritus in hepatitis is commonly related to cholestasis and bile salt deposition, and nursing care focuses on soothing the skin while preventing excoriation and secondary infection. Cool, moist compresses reduce local irritation and provide symptomatic relief without drying the skin. In contrast, hot baths tend to increase vasodilation and can worsen itching and dry the skin. Vigorous rubbing with towels or using exfoliating brushes increases skin trauma, raising the risk of breakdown and infection in an already uncomfortable patient.

Question 32

A client asks the nurse what is the purpose of applying a cold pack to a sprained ankle. What is the best response by the nurse?

Accepted Answer

Answer reason: Cold therapy causes peripheral vasoconstriction, which limits capillary bleeding and fluid leakage into tissues after an acute sprain, thereby reducing edema. It also slows local cellular metabolism and decreases the inflammatory response, which helps control pain in the first 24–48 hours. Options describing increased circulation or vasodilation are more consistent with heat therapy, not cold, and would be less appropriate early after injury. While cold can provide some analgesia via decreased nerve conduction, the primary purpose in an acute sprain is minimizing swelling through vasoconstriction.

Question 33

A client has just returned home and the hospice nurse is visiting for the first time. The client complains of a lot of pain. In addition to the physician and the nurse, what member of the care team will assist in providing comfort therapies for this client?

Accepted Answer

Answer reason: Hospice care emphasizes symptom relief and quality of life using both pharmacologic and nonpharmacologic comfort measures. Massage is a common complementary therapy used to reduce pain perception, promote relaxation, and decrease anxiety, and it can be integrated into a comfort plan without changing the primary medical regimen. Physical therapy and occupational therapy focus more on mobility, function, and safety with ADLs rather than direct comfort-focused pain-relief modalities. A nutritionist supports dietary needs and cachexia management but is not primarily responsible for comfort therapies targeting pain.

Question 34

A client who has difficulty rating pain is noted to have the following vital signs. Which of these indicates to the nurse that pain may be present?

Accepted Answer

Answer reason: Acute pain commonly triggers a sympathetic (“fight-or-flight”) response, leading to tachycardia and sometimes hypertension, especially when the patient cannot reliably self-report. A heart rate of 120 beats/minute is a notable physiologic sign that can accompany significant pain and should prompt further assessment for other pain behaviors and causes. The listed blood pressure is within a typical normal range and is less suggestive of pain-related stress. Bradypnea (RR 8) and borderline oxygenation (SpO2 92%) point more toward respiratory depression or impaired gas exchange rather than pain as the primary driver.

Question 35

The nurse is caring for a hearing-impaired client in the coronary care unit. To reduce sensory overload for the client, it is most important for the nurse to do what?

Accepted Answer

Answer reason: Hearing impairment often forces the client to rely more heavily on visual cues and heightened attention to the environment, which increases the risk of sensory overload and fatigue in a high-stimulus unit. Unnecessary talk at the bedside adds competing stimuli and makes it harder for the client to focus on essential communication and cues. Reducing nonessential conversation is a direct, high-impact way to decrease environmental stimulation while preserving needed interaction and safety-related communication. In contrast, simply dimming lights or drawing curtains may reduce some stimulation but does not address the constant, confusing auditory/communication clutter that most directly drives overload in this situation.

Question 36

A nurse is teaching a client postoperative coughing and deep-breathing exercises. What is the most important information to include?

Accepted Answer

Answer reason: Deep breathing before coughing helps expand alveoli and mobilize secretions, reducing atelectasis and postoperative pneumonia risk. Incisional splinting supports the surgical site, decreases pain, and allows a more forceful, effective cough without excessive strain on the incision. Teaching coughing alone without the preceding deep breath is less effective for ventilation and secretion clearance. Positioning details are secondary; the essential sequence is splint, deep breathe, then cough to maximize pulmonary hygiene and comfort.

Question 37

The NA reports to the nurse that the client with CRF has “white crystals” and dry, itchy skin. Based on this information, which instruction should the nurse give to the NA?

Accepted Answer

Answer reason: Uremic pruritus in chronic renal failure is commonly related to uremic “frost” (crystallized urea) on the skin and is best relieved initially with gentle skin care and comfort measures. Tepid water helps cleanse away the crystals while minimizing additional drying and irritation that can occur with hot water. This is an appropriate task for the NA and supports comfort without requiring clinical judgment or medication administration. By contrast, applying a prescribed cream would require following medication orders and facility policy for delegated tasks, and assessing for breakdown is a nurse assessment activity rather than an NA intervention.

Question 38

The nurse is providing teaching to the client with COPD about the purpose of pursed-lip breathing. Which explanation is most appropriate?

Accepted Answer

Answer reason: Pursed-lip breathing is a nonpharmacologic breathing technique used in COPD to improve ventilation efficiency by controlling exhalation and reducing the work of breathing. By creating mild back-pressure during exhalation, it helps keep small airways from collapsing and supports more complete emptying of trapped air, which improves breathing mechanics during dyspnea. This coached pattern can enhance effective use of the diaphragm and accessory muscles over time, making breathing feel easier during exertion. Options about reducing inflammation or improving inhaled medication delivery do not describe the primary physiologic purpose of the technique. Although it may help the client feel calmer, the mechanism is not primarily via slowing heart rate.

Question 39

The client with interstitial pulmonary disease is experiencing dyspnea and fatigue. Which recommendation by the nurse will be most helpful to this client?

Accepted Answer

Answer reason: Teaching energy conservation (pacing, planning rest periods, sitting for tasks, avoiding unnecessary exertion) directly decreases oxygen demand and helps manage both dyspnea and fatigue throughout daily activities. Oxygen may be appropriate only if hypoxemia is present/prescribed, so it is not the most universally helpful recommendation based on the stem alone. Upright positioning can ease breathing transiently, and controlled coughing targets secretion clearance, which is not the primary problem in restrictive interstitial disease.

Question 40

The nurse is caring for a client with osteoarthritis of the knee. The nurse determines that discharge teaching has been effective when the client makes which statement?

Accepted Answer

Answer reason:  Heat therapy helps decrease joint stiffness and pain in osteoarthritis by promoting muscle relaxation and improving local circulation, especially after periods of inactivity such as overnight rest. Morning warmth can improve mobility and function, aligning with safe self-management teaching for knee osteoarthritis. Taking ibuprofen on an empty stomach increases risk of GI irritation/ulceration and is incorrect teaching. High-impact exercise like jogging can worsen joint pain and degeneration; lower-impact activity is typically recommended instead.

Question 41

The nurse is caring a client who has been admitted to the hospital with a musculoskeletal injury. Cold therapy is ordered for which of the following reasons?

Accepted Answer

Answer reason: Cold application produces local vasoconstriction, which decreases capillary permeability and limits bleeding and fluid leakage into tissues, thereby reducing swelling after acute injury. It also slows nerve conduction velocity, providing analgesia and helping limit reflex muscle guarding/spasm. In contrast, heat is the modality that increases circulation via vasodilation and is typically used for stiffness and chronic muscle spasm rather than acute inflammation. Therefore cold therapy is ordered primarily to minimize edema and pain while limiting spasm in the early injury phase.

Question 42

Which is a common misconception about pain?

Accepted Answer

Answer reason: Pain is subjective and must be assessed based on the client’s self-report rather than inferred from diagnosis severity. The same condition can produce very different pain experiences due to factors like anxiety, prior pain experiences, culture, and coping mechanisms. Assuming “more severe illness equals more pain” leads to undertreatment and biased assessment. A key nursing principle is to accept the client’s report of pain and evaluate response to interventions rather than relying on objective disease severity.

Question 43

The nurse admits the temi newborn, who is at risk to develop neonatal abstinence syndrome (NAS), to the newborn nursery. The nurse correctly places this infant in which location?

Accepted Answer

Answer reason: A quiet, dim environment supports sleep and self-regulation and can reduce the need for escalating pharmacologic management. Placing the infant with many other newborns or in a well-lit, busy area increases noise and light exposure that can worsen symptoms. Positioning near a high-traffic workstation also increases stimulation and disrupts rest, which is countertherapeutic for NAS care.

Question 44

The client is receiving 2 liters of oxygen by nasal cannula. Which rationale should the nurse use to explain the reason for oxygen being bubbled through a humidifier?

Accepted Answer

Answer reason: Humidification adds water vapor to the flow, helping maintain mucosal integrity and reducing irritation, thick secretions, and epistaxis. This is especially relevant as flow rate and duration of therapy increase, even though routine humidification is most emphasized at higher flows. The other options do not reflect the primary physiologic purpose of a humidifier in low-flow oxygen delivery.

Question 45

A Native American client experiences chronic pain associated with rheumatoid arthritis. The nurse is aware that culture is an important factor in the perception and treatment of pain. Without stereotyping, the nurse knows many Native Americans employ which practice to combat pain?

Accepted Answer

Answer reason: Culturally influenced, nonpharmacologic pain-relief practices are part of holistic comfort management and should be incorporated when safe and desired by the client. Many Native American traditions include ceremonial heat/steam practices (often described as sweat lodges or sweat baths) that may be used to relieve discomfort and promote well-being. In contrast, moxibustion and acupuncture are more commonly associated with Traditional Chinese Medicine, and yin-yang is a belief framework rather than a specific pain-control procedure. The nurse should still assess the individual client’s preferences, safety risks (e.g., dehydration, heat intolerance), and coordinate care respectfully.

Question 46

The nurse on the rehabilitation unit is admitting a visually impaired elderly client for cardiac rehabilitation therapy. What plan should the nurse include to reduce sensory deprivation for a visually impaired client?

Accepted Answer

Answer reason: Sensory deprivation risk increases when environmental stimulation is reduced, so nursing care should maximize safe, meaningful sensory input. For a visually impaired older adult, increasing ambient lighting during daytime can improve remaining visual acuity, enhance orientation, and reduce isolation. Dimming lights or closing blinds decreases visual cues and can worsen disorientation and reduced stimulation. While glare can be problematic for some clients, the most global plan to prevent deprivation is providing adequate daylight/lighting rather than reducing it.

Question 47

After touching a hot oven grate, the client telephones the ED asking for advice for the singed fingers. Which initial statement by the nurse is most appropriate?

Accepted Answer

Answer reason:  Immediate first aid for a minor thermal burn is rapid cooling with cool (not ice) running water to stop ongoing thermal injury, decrease pain, and limit burn depth. Ice or very cold applications can cause vasoconstriction and additional tissue damage, especially on digits. Advising an ED visit may be appropriate if there are red flags (deep burn, circumferential injury, blistering with neurovascular changes), but it is not the best initial instruction for an uncomplicated contact burn. Topical antibiotics are not the first step and are typically considered after cooling and gentle cleansing if indicated.

Question 48

The nurse is discharging the client home with a plaster of Paris cast to the lower leg. Which self-care recommendation should the nurse include?

Accepted Answer

Answer reason: Cast care teaching emphasizes keeping the cast dry and maintaining skin integrity; itching should be managed without introducing moisture or foreign material under the cast. Cool air can provide symptomatic relief while minimizing risk of skin breakdown and infection. Powders and objects placed inside the cast can cake, abrade the skin, and hide pressure injuries. Submerging or washing a plaster cast with water (especially hot, soapy water) can soften and weaken it, compromising immobilization and increasing complication risk.

Question 49

The nurse identifies the nursing problem of ineffective airway clearance for the postoperative client following an open thoracotomy. Which priority intervention best addresses this nursing problem?

Accepted Answer

Answer reason: Effective airway clearance after thoracotomy depends on the patient being able to cough, deep-breathe, and use incentive spirometry to mobilize secretions. Uncontrolled incisional pain leads to splinting and shallow respirations, which directly worsens secretion retention and atelectasis risk. Providing adequate analgesia is therefore the most immediate, high-impact intervention that enables the patient to perform airway-clearance behaviors safely and effectively. Increasing fluids may help thin secretions but is slower-acting and does not remove the key barrier to coughing, while leg/foot exercises and pneumatic compression primarily target venous thromboembolism prevention rather than airway clearance.

Question 50

The client's daughter tells the nurse of frustration while communicating with her elderly mother who wears hearing aids. Which intervention should the nurse suggest to the client's daughter?

Accepted Answer

Answer reason: Effective communication with hearing impairment starts by ensuring the listener is ready to receive the message and can use visual and auditory cues. Getting the person’s attention first (calling their name, gently touching an arm, making eye contact) reduces missed initial words and supports lip-reading and focus, improving comprehension. Speaking into the “better ear” can help, but it is secondary to first establishing attention and appropriate positioning, and “directly into” the ear may distort sound or feel intrusive. Exaggerated mouth movements and minimizing communication can worsen understanding and increase frustration by reducing clarity and engagement.

Train with a large NCLEX question bank and jump into a full exam-style simulator

Non-Pharmacological Comfort Interventions NCLEX Practice Test

Continue Learning