Question 1

The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to?

Accepted Answer

Answer reason: Pain is subjective; the patient’s self-report using a numeric rating scale is the most accurate and reliable assessment. Vital signs and facial expressions are indirect, and asking yes/no lacks quantification.

Question 2

The nurse is caring for a client with a diagnosis of hepatitis who is experiencing pruritus. Which would be the most appropriate nursing intervention?

Accepted Answer

Answer reason: Hepatitis-related pruritus is eased by skin lubrication and cool/tepid bathing. Adding an emollient (baby oil) to bath water moisturizes the skin and reduces itching, whereas hot water and powders dry and irritate the skin.

Question 3

The nurse is caring for a client with Rheumatoid Arthritis. Which nursing diagnosis should receive PRIORITY in the plan of care?

Accepted Answer

Answer reason: For rheumatoid arthritis, pain relief is the immediate priority; the nursing diagnosis focusing on comfort directly addresses pain, outranking risks or mobility/self-care issues.

Question 4

A female client diagnosed with genital herpes simplex virus 2 complains of dysuria, dyspareunia and leukorrhea and lesions on the labia and perianal skin. A PRIMARY nursing action should be to?

Accepted Answer

Answer reason: Warm sitz baths soothe painful genital lesions, promote hygiene, and reduce inflammation, providing primary comfort care for acute HSV symptoms.

Question 5

The nurse is teaching a client with chronic obstructive pulmonary disease to use occasional pursed-lip breathing. What is the MAJOR reason for this?

Accepted Answer

Answer reason: Pursed-lip breathing creates back-pressure during exhalation (PEEP), prolonging expiration and helping keep small airways and alveoli from collapsing, which improves ventilation in COPD.

Question 6

A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions?

Accepted Answer

Answer reason: Upright positioning (chair/high Fowler's) reduces venous return and pulmonary congestion, lowering cardiac workload and easing breathing in CHF. Supine, left lateral, and low Fowler's do not provide this benefit.

Question 7

A client has developed thrombophlebitis of the left leg. Which of the following nursing interventions should be given the HIGHEST priority?

Accepted Answer

Answer reason: Elevating the affected leg reduces venous pressure and edema in acute thrombophlebitis, lowering discomfort and risk of complications. Support stockings can increase pressure and are not used during the acute phase; warm compresses may be helpful but are secondary; bed rest alone does not address edema.

Question 8

A nurse is caring for a client with peripheral arterial insufficiency of the lower extremities. Which one of the following should be included in the plan of care to reduce leg pain?

Accepted Answer

Answer reason: Dependent leg positioning increases arterial perfusion to ischemic limbs, relieving pain. Elevation and cold cause further ischemia/vasoconstriction; caffeine is vasoconstrictive.

Question 9

A client has bilateral knee pain from osteoarthritis. In addition to taking the prescribed NSAID, the nurse should instruct the client to?

Accepted Answer

Answer reason: For osteoarthritis, regular low-impact exercise strengthens supporting muscles and maintains joint mobility, reducing pain. Prolonged rest increases stiffness, dietary citrus is unrelated, and leg elevation is not a key intervention for OA.

Question 10

A client asks the nurse to explain the basic ideas of homeopathic medicine. The response that BEST explains this approach is that remedies?

Accepted Answer

Answer reason: Homeopathy uses very small doses of substances to stimulate the body’s own defenses; it aims to enhance self-healing, effectively boosting the immune system rather than directly killing pathogens or altering fluids or energy.

Question 11

The nurse is teaching home care to the parents of a child with acute spasmodic croup. The MOST important aspect of this care is?

Accepted Answer

Answer reason: For viral spasmodic croup, the priority home care is moisture and hydration to soothe inflamed airways and thin secretions for easier clearance. Antibiotics are not indicated, and sedation or antihistamines can depress respirations or dry secretions.

Question 12

The nurse knows which of the following is an important consideration in the care of a newborn with fetal alcohol syndrome?

Accepted Answer

Answer reason: Infants with fetal alcohol syndrome are easily overstimulated and hyperirritable; care focuses on minimizing stimuli and gentle, minimal handling. The other options are not primary or routine priorities for FAS newborns.

Question 13

The nurse is caring for a client with Ménière’s disease. The nurse stands directly in front of the client when speaking. Which of the following BEST describes the rationale for the nurse’s position?

Accepted Answer

Answer reason: Turning the head can worsen vertigo in Ménière’s disease. Standing directly in front allows the client to keep the head still, reducing vertigo and promoting safety.

Question 14

What should be the temperature of water used for cold sponging?

Accepted Answer

Answer reason: Cold sponging is performed with cool water, typically around 60–70°F, to reduce body temperature safely. 70°F is appropriate; warmer temperatures are not cold and 0°F is unsafe.

Question 15

The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the parents to?

Accepted Answer

Answer reason: Atopic dermatitis is intensely pruritic; scratching worsens lesions and risks infection. Covering hands with mittens or socks prevents scratching. The rash is not contagious, warm clothing can increase itching, and detergents irritate skin.

Question 16

The nurse is caring for a client with COPD who becomes dyspneic. The nurse should?

Accepted Answer

Answer reason: Pursed-lip breathing prolongs exhalation, reduces air trapping, and eases dyspnea in COPD. Paper-bag breathing is inappropriate, high-flow oxygen at 6 L/min can suppress respiratory drive, and positioning alone is less effective than coaching the breathing technique.

Question 17

Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

Accepted Answer

Answer reason: With arterial/vascular occlusion, direct heat and vigorous rubbing can injure ischemic tissue or dislodge clots, and increasing fluids won’t address cold feet. Providing slipper socks safely warms the feet and promotes comfort.

Question 18

The mother of a school-aged child in a long leg cast asks the nurse how to relieve itching inside the cast. Which of the following is appropriate for the nurse to suggest as a remedy?

Accepted Answer

Answer reason: Ice applied over the cast safely relieves itching without inserting objects or using heat. Inserting objects risks skin injury and infection; heat can cause burns and increase swelling.

Question 19

Which of the following is considered the fifth vital sign in the emergency department?

Accepted Answer

Answer reason: Pain is considered the fifth vital sign; the other options are neurologic assessments, not vital signs.

Question 20

Which item below would be the best thing to apply to a swollen head injury to reduce swelling?

Accepted Answer

Answer reason: Cold therapy reduces acute soft-tissue swelling by causing local vasoconstriction. A bag of frozen vegetables conforms to the area and, when wrapped in cloth, protects the skin from frost injury. A wet cloth is usually not cold enough to be effective, and a metal can of soft drink is unsafe and does not conform well to the injury.

Question 21

A 59-year-old patient is suffering from severe pain, numbness, and tingling in the lower legs and feet as a result of diabetic peripheral neuropathy. Which type of non-pharmacological intervention would be most appropriate for pain management in this patient?

Accepted Answer

Answer reason: Percutaneous electrical nerve stimulation (PENS) provides targeted electrical stimulation to peripheral nerves, engaging inhibitory pathways and endorphin release to reduce neuropathic pain. It has evidence of benefit for painful diabetic peripheral neuropathy and is an appropriate non-pharmacologic option. Reiki lacks robust clinical evidence, and low-level laser or electromagnetic field therapies have inconsistent or limited support and are not first-line.

Question 22

What is the main benefit of therapeutic massages is?

Accepted Answer

Answer reason: Therapeutic massage is a nonpharmacologic comfort measure primarily used to promote relaxation, enhance circulation, and help relieve muscle tension. It is not intended as a primary treatment to reduce edema/fluid retention, heal diabetic tissue damage (which may be contraindicated with impaired sensation/vascular disease), or treat duodenal ulcers. Therefore, the most accurate general benefit listed is improved circulation and muscle tone.

Question 23

Which position helps in secretion drainage from lungs?

Accepted Answer

Answer reason: Postural drainage uses gravity-assisted positioning (often including Trendelenburg variations when appropriate) to mobilize bronchial secretions from specific lung segments toward the central airways for expectoration or suctioning. Fowler’s position primarily improves lung expansion and reduces work of breathing, but it is not specifically designed to drain secretions. Lithotomy is for gynecologic/rectal procedures, and prone positioning may improve oxygenation in some conditions but is not the standard method for secretion drainage.

Question 24

Which type of suctioning is used in a tracheostomy patient?

Accepted Answer

Answer reason: A tracheostomy creates a direct airway opening into the trachea, so secretions are removed by suctioning through the tracheostomy tube (tracheal suction). Oral or nasal suctioning targets upper-airway secretions and does not clear the trachea effectively in a tracheostomy-dependent airway. “Endotracheal suction” refers to suctioning via an endotracheal tube used for oral/nasal intubation, not a tracheostomy tube. Therefore, tracheal suction is the appropriate technique.

Question 25

After dinner, during hourly rounding, a client awakes to report they feel like "food is coming up" in the back of their throat and that there is a bitter taste in their mouth. What nursing intervention will the nurse perform next?

Accepted Answer

Answer reason: The symptoms (regurgitation sensation and bitter taste) are most consistent with gastroesophageal reflux, and the immediate nursing action is to position the client to reduce reflux and aspiration risk. Semi-Fowler’s uses gravity to decrease gastric contents moving upward and helps protect the airway. Deep suctioning is not indicated without evidence of aspiration or airway obstruction. Keeping the client NPO and avoiding milk products are not the immediate next interventions for acute reflux symptoms during rounding.

Question 26

Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet and should the nurse take to enhance the client’s comfort? Which of the following nursing actions?

Accepted Answer

Answer reason: In a client with vascular occlusion and impaired peripheral perfusion, warming should be provided safely without risking burns or increasing tissue injury. Slipper socks provide gentle insulation to improve comfort while avoiding direct heat or vigorous friction. Brisk rubbing can traumatize ischemic tissue, and a heating pad can cause burns due to decreased sensation and poor blood flow. Increasing oral fluids does not directly address localized cold feet from arterial insufficiency.

Question 27

A client with rheumatoid arthritis complains of morning stiffness. What should the nurse suggest?

Accepted Answer

Answer reason: Rheumatoid arthritis commonly causes morning stiffness that improves with gentle movement and heat. Warm moist heat helps increase blood flow, relax muscles, and decrease joint stiffness to prepare for activity. Ice is more useful for acute inflammation/swelling and can worsen stiffness. Avoiding movement promotes immobility and can increase stiffness, while taking NSAIDs after meals addresses GI tolerance rather than specifically relieving morning stiffness.

Question 28

A client is in a plaster cast for a tibia fracture. The client reports itching under the cast. What is the most appropriate nursing response?

Accepted Answer

Answer reason: Cool air from a hairdryer can reduce itching under a cast without introducing objects or substances that could damage skin or the cast. Inserting items (like a pencil) can cause skin breakdown, bleeding, and infection that cannot be easily assessed under the cast. Talcum powder can cake and irritate skin and increase moisture, raising infection risk. Tapping may provide minor distraction but is less effective than safely cooling and drying the area.

Question 29

Which of the following interventions on the part of the nurse would most help lessen a confused ambulatory client find their room?

Accepted Answer

Answer reason: For a confused, ambulatory client, environmental cues that are simple, concrete, and easily recognized are most effective for wayfinding. A picture cue on the door provides a strong visual landmark and reduces reliance on memory, reading ability, or repeated re-orientation. Large room numbers may still be difficult to interpret for clients with cognitive impairment, and hourly orientation is less effective than consistent environmental supports. Pinning the room number on the client’s attire is less helpful for navigation and may be lost or overlooked.

Question 30

A client with Graves' disease asks about eye care. What should the nurse recommend?

Accepted Answer

Answer reason: Graves' disease can cause exophthalmos and eyelid retraction, leading to corneal dryness, irritation, and risk of injury. Artificial tears help lubricate and protect the cornea, and dark glasses reduce photophobia and shield the eyes from wind and debris. Warm compresses are not the key intervention for exposure-related dryness, topical steroid cream is not appropriate without a prescription/diagnosis, and eye exercises do not address corneal exposure and dryness.

Question 31

A nurse is caring for a laboring client whose cervix is 6 cm dilated, and she reports severe back pain. The nurse suspects fetal occiput posterior position. What is the best nursing intervention?

Accepted Answer

Answer reason: Occiput posterior positioning commonly causes intense back labor due to fetal head pressure on the maternal sacrum. Applying firm counterpressure to the sacral area is an effective nonpharmacologic comfort measure that can significantly reduce pain during contractions. Trendelenburg does not relieve back labor and can be unsafe/unnecessary, and oxytocin is a provider-managed medication intervention not indicated solely for pain relief. Ambulation or position changes may help, but counterpressure is the most direct and effective nursing action for severe sacral back pain.

Question 32

The best position for a pneumonia patient with difficulty breathing is?

Accepted Answer

Answer reason: Semi-Fowler’s position (head of bed elevated) promotes lung expansion by decreasing pressure from abdominal contents on the diaphragm, improving ventilation and easing work of breathing in pneumonia. It also helps coughing and mobilization of secretions compared with lying flat. Supine positioning can worsen dyspnea and oxygenation, and Trendelenburg increases diaphragmatic pressure and aspiration risk. Prone is not the routine first-line nursing position for uncomplicated pneumonia-related dyspnea.

Question 33

The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion?

Accepted Answer

Answer reason: For nasogastric tube insertion, positioning the client upright (High Fowler’s) promotes neck flexion and aligns the nasopharynx and esophagus, making passage easier. It also reduces aspiration risk by improving airway protection and allowing the client to swallow as the tube advances. Low Fowler’s or supine positions increase risk of misplacement into the airway and aspiration. The right-side position is typically used after placement to facilitate gastric emptying in some situations, not for insertion.

Question 34

Th nurse is teaching a client with emphysema about interventions to improve shortness of breath during dyspneic episodes. Which position should the nurse instruct the client to use?

Accepted Answer

Answer reason:  Sit upright and lean forward in tripod position. The tripod position optimizes breathing mechanics in emphysema by fixing the shoulder girdle so accessory muscles (e.g., sternocleidomastoid, scalene) can better assist ventilation. Leaning forward also helps improve diaphragmatic excursion and reduces the work of breathing during acute dyspnea. Compared with simply sitting upright or reclined, tripod positioning more reliably decreases air trapping sensation and improves ventilation in COPD exacerbations.

Question 35

A nurse is caring for a patient with COPD. Which of the following should the nurse include in the patients care plan?

Accepted Answer

Answer reason: Teach the patient the pursed lip breathing for periods of dyspnea Pursed-lip breathing helps keep airways open longer during exhalation, reduces air trapping, and improves ventilation in COPD, which can relieve dyspnea. Advising complete avoidance of activity is inappropriate because graded activity with rest periods helps maintain conditioning and functional status. While hydration can help thin secretions, recommending 3–4 L daily is not universally safe (e.g., heart failure, renal disease) and is not the most targeted, standard dyspnea intervention compared with pursed-lip breathing.

Question 36

A patient with COPD should be encouraged to use pursed-lip breathing?

Accepted Answer

Answer reason: True Pursed-lip breathing is recommended for COPD because it prolongs exhalation, helps prevent airway collapse, and reduces air trapping/hyperinflation. This can improve ventilation, decrease dyspnea, and promote better gas exchange during episodes of shortness of breath. It is a simple, nonpharmacologic technique that patients can use during activity or acute breathlessness.

Question 37

A client with delirium becomes agitated and confused at night. The best initial intervention is which of the following?

Accepted Answer

Answer reason: Clients with delirium often worsen at night (“sundowning”) and benefit from reducing sensory overload while providing gentle orientation cues. Turning off the TV decreases confusing stimulation, and a night light helps prevent disorientation and falls without overly stimulating the client. Keeping a TV on or maintaining a well-lit room can increase stimulation and disrupt sleep, potentially worsening agitation. Moving the client near the nurse’s station may help supervision, but environmental calming and reorientation is the best initial step.

Question 38

A patient with COPD is receiving discharge instructions. Which statement by the patient indicates correct understanding?

Accepted Answer

Answer reason: Pursed-lip breathing prolongs exhalation, helps prevent airway collapse, and improves ventilation in COPD, reducing dyspnea and anxiety. Increasing oxygen flow independently (e.g., to 6 L/min) is unsafe and should be done only as prescribed because excessive oxygen can worsen hypercapnia in some COPD patients. Fluids are generally encouraged (unless contraindicated) to help thin secretions, and prolonged bed rest increases deconditioning; patients should pace activities with rest periods rather than stay in bed most of the day.

Question 39

A client who has pancreatitis is experiencing pain. After administering an analgesic, the nurse should place the client in which of the following positions to promote comfort?

Accepted Answer

Answer reason:This position helps decrease abdominal pressure and reduces tension on the inflamed pancreas, which can lessen pain. It may also improve diaphragmatic excursion and patient comfort compared with lying flat, which can worsen epigastric pain. Positioning is an important nonpharmacologic adjunct to analgesics in acute pancreatitis.

Question 40

A client with rheumatoid arthritis reports morning stiffness. What advice should the nurse provide?

Accepted Answer

Answer reason: Heat helps decrease joint stiffness and pain in rheumatoid arthritis by promoting muscle relaxation and improving local circulation, which is especially useful after overnight immobility. Cold is more helpful for acute inflammation and swelling, not typical morning stiffness relief. Vigorous ROM can worsen pain and inflammation; gentle range-of-motion and stretching are preferred. Prolonged resting before getting up can increase stiffness rather than reduce it.

Question 41

A patient is having difficulty breathing due to COPD. What is the most effective position for improving ventilation?

Accepted Answer

Answer reason: Leaning forward in an upright posture optimizes diaphragmatic excursion and allows accessory muscles to assist breathing, which improves alveolar ventilation in COPD. This position also decreases the work of breathing by improving chest wall mechanics and can reduce air trapping during exhalation. In contrast, supine and prone positions generally worsen ventilation in obstructive disease by limiting lung expansion, and side-lying does not provide the same mechanical advantage for dyspnea relief.

Question 42

A client with rheumatoid arthritis complains of morning stiffness. What is the nurse’s best advice?

Accepted Answer

Answer reason: Heat helps reduce rheumatoid arthritis morning stiffness by increasing blood flow, decreasing joint viscosity, and promoting muscle relaxation. Warm water or moist heat is typically preferred for stiffness, whereas cold is more useful for acute inflammation and swelling. Gentle activity after warming the joints can improve function, so advising complete avoidance of morning exercise is not appropriate. Passive ROM alone is insufficient because clients benefit from active, gentle movement as tolerated.

Question 43

A client with suspected appendicitis arrives at the ED. What is the best position to provide comfort while awaiting surgery?

Accepted Answer

Answer reason: This positioning reduces tension on the abdominal muscles and peritoneum, which can lessen pain from appendiceal inflammation. Elevating the head of the bed and flexing the hips/knees decreases stretching of the right lower quadrant and can promote comfort while minimizing unnecessary movement. Other positions (supine with legs straight, Trendelenburg) can increase abdominal muscle stretch or discomfort, and left lateral is not typically the most effective comfort position for suspected appendicitis.

Question 44

The nurse is caring for a patient with epistaxis (nosebleed). Which position is correct?

Accepted Answer

Answer reason: Leaning forward helps prevent blood from running into the posterior pharynx, which reduces the risk of aspiration, airway compromise, nausea/vomiting, and swallowing blood. Semi-Fowler’s promotes comfort and supports breathing while allowing direct pressure to be applied to the soft part of the nose if needed. Positions that tilt the head back or place the patient supine/Trendelenburg increase the likelihood of blood pooling in the throat and obscuring ongoing bleeding.

Question 45

Following surgery, Mario complains of mild incisional pain while performing deep-breathing and coughing exercises. The nurse's best response would be?

Accepted Answer

Answer reason: " Splinting the incision supports the wound during coughing/deep breathing, which reduces pain and decreases stress on the suture line. This enables the client to perform pulmonary hygiene more effectively, helping prevent atelectasis and pneumonia in the postoperative period. The other responses are either non-therapeutic reassurance or delay an immediate, safe comfort measure that promotes effective breathing exercises.

Question 46

When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote?

Accepted Answer

Answer reason: After thoracotomy and lobectomy, pain limits chest expansion, leading to shallow respirations, atelectasis, and retained secretions. Effective analgesia enables the client to perform pulmonary hygiene (deep breathing, coughing, incentive spirometry) to improve ventilation and prevent postoperative respiratory complications such as pneumonia. While comfort, sleep, and mobility are important, the most critical postoperative goal supported by pain control in this context is optimizing pulmonary function.

Question 47

Method of prevention is to avoid exposure to an infection person. Nursing responsibility for rehabilitation of patient includes the provision of?

Accepted Answer

Answer reason: Rehabilitation nursing focuses on helping the patient regain function and cope with limitations through supportive care, symptom relief, and assistance with activities of daily living. Measures like terminal disinfection, immunization, and gamma globulin are preventive/public health interventions aimed at reducing transmission or susceptibility, not restoring function after illness. Providing comfort and supportive nonpharmacologic care is a core nursing responsibility during the rehab phase to promote recovery and quality of life.

Question 48

Which of the following is used for assessing the pain in children?

Accepted Answer

Answer reason: Children, especially those who are young or have limited language skills, often cannot reliably use numeric or complex descriptive scales. The Wong-Baker Faces scale uses facial expressions to match the child’s perceived pain intensity, making self-report feasible and developmentally appropriate. It is widely used in pediatric settings to standardize pain assessment and guide comfort and analgesia decisions.

Question 49

A nurse is planning care for a newborn who has neonatal abstinence syndrome. Which of the following interventions should the nurse include in the plan of care?

Accepted Answer

Answer reason: Neonatal abstinence syndrome causes autonomic instability and CNS irritability (e.g., tremors, high-pitched cry, poor sleep), so care focuses on decreasing stimulation and promoting comfort. Swaddling in a flexed position provides containment, reduces excessive motor activity, and helps the infant self-regulate. Increasing visual stimulation would worsen symptoms, and routine weighing frequency does not address acute withdrawal needs. Parental involvement is generally encouraged (rooming-in, soothing, feeding support) unless there is an immediate safety concern, so discouraging interaction is not appropriate as a standard intervention.

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

Non-Pharmacological Comfort Interventions NCLEX Practice Test

Continue Learning