Question 1

An infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at a well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which intervention should the nurse suggest to the parent?

Accepted Answer

Answer reason: Local redness and swelling after DTaP is a common, expected injection-site reaction. A cold compress helps reduce local inflammation, pain, and edema via vasoconstriction and is an appropriate first-line home comfort measure. Returning to clinic is unnecessary unless there are signs of a severe reaction (e.g., extensive swelling, high fever, hives, respiratory symptoms). Monitoring for fever can be advised, but it does not directly address the reported local reaction and is not the best single intervention.
Category reason: This question tests a nursing comfort intervention and home-care advice for a common post-immunization injection-site reaction, which fits non-pharmacologic symptom relief within Basic Care and Comfort.

Question 2

A 5-month-old admitted with gastroenteritis is managed with IV fluids and is to be NPO. Which nursing intervention will provide the most comfort for the 5-month-old who is NPO?

Accepted Answer

Answer reason: At 5 months, infants have a strong need for non-nutritive sucking for self-soothing and regulation. When the infant is NPO, hunger and stress can increase irritability, and a pacifier provides comfort without violating NPO status. The other options may be calming but are generally less consistently effective than non-nutritive sucking for immediate soothing in this age group.
Category reason: This question asks for the best nursing comfort measure for an NPO infant, focusing on nonpharmacologic interventions to promote comfort.

Question 3

A nurse is caring for a patient with congestive heart failure who reports shortness of breath, has bilateral crackles, and +3 pitting edema in the lower extremities. Which of the following actions should the nurse take first?

Accepted Answer

Answer reason: This is the immediate airway/breathing intervention for acute dyspnea with crackles, improving lung expansion and reducing venous return/preload to decrease pulmonary congestion. It can be implemented instantly and does not require waiting for orders or medication onset. Elevating the legs can worsen pulmonary congestion by increasing venous return. Diuretics and notifying the provider are important next steps, but positioning addresses the most urgent problem first (oxygenation/ventilation).
Category reason: This item tests nursing prioritization of an immediate nonpharmacologic intervention (positioning) to improve breathing in a symptomatic heart-failure patient, which fits Basic Care and Comfort.

Question 4

A client calls the nurse to report exacerbation of chronic lower back pain after working in the yard all weekend. Knowing that this worsened back pain is probably due to acute inflammation, the nurse recommends which nonpharmacologic intervention?

Accepted Answer

Answer reason: Acute inflammation from overuse is best managed initially by avoiding activities that worsen symptoms to limit ongoing tissue irritation and allow healing. Heat and stretching are more appropriate after the acute inflammatory phase or when muscle spasm/stiffness predominates, as they can increase blood flow and potentially exacerbate early inflammation. Comfort positioning can help symptom control but does not address the key trigger (continued mechanical aggravation) as directly as activity modification and relative rest.
Category reason: This question tests the nurse’s selection of an appropriate nonpharmacologic comfort/pain-management intervention in a client care scenario, which aligns with Basic Care and Comfort—Non-Pharmacological Comfort Interventions.

Question 5

Which position is used for a patient with respiratory distress?

Accepted Answer

Answer reason: c) Fowler's This position promotes maximal chest expansion and improves diaphragmatic descent, which reduces work of breathing in respiratory distress. Upright positioning also enhances ventilation/perfusion matching and can improve oxygenation by reducing atelectasis. Supine and Trendelenburg can worsen dyspnea by increasing diaphragmatic elevation and venous return, while prone is generally reserved for specific indications (e.g., severe ARDS) and is not the routine immediate comfort position.
Category reason: This item tests an immediate nursing intervention (therapeutic positioning) to improve breathing and comfort in a symptomatic patient, which fits Basic Care and Comfort—Non-Pharmacological Comfort Interventions.

Question 6

A newborn with opioid withdrawal is irritable, has a high-pitched cry, and is jittery. What is the best nursing intervention?

Accepted Answer

Answer reason: Opioid withdrawal (neonatal abstinence syndrome) causes CNS irritability and autonomic dysregulation, so reducing environmental stimuli helps decrease tremors, high-pitched crying, and sleep disruption. First-line supportive care emphasizes a dark, quiet setting, gentle handling, and clustered care to prevent overstimulation and escalation of symptoms. Rocking can increase stimulation, hourly formula feeds are not indicated and can worsen GI upset/overfeeding, and a pacifier may help self-soothing but is less foundational than controlling the environment.
Category reason: This question asks for the most appropriate nursing comfort measure to manage withdrawal symptoms in a newborn, which is primarily a patient-care intervention rather than foundational science knowledge.

Question 7

A diabetic patient says, "I am afraid I cannot inject insulin by myself." The nurse responds, "I will help you practice until you are confident." Which step is this?

Accepted Answer

Answer reason: This is the action phase of the nursing process, where the nurse carries out interventions to help the client achieve goals. Assisting the patient to practice self-injection is a direct nursing intervention (teaching/coaching and skill practice). Diagnosis would identify the problem (e.g., knowledge deficit or anxiety), planning would set goals and choose strategies, and evaluation would assess whether the client can self-inject safely and confidently.
Category reason: This item tests the nursing process by asking which step applies to a specific nurse action (coaching/practice), which is a patient-care decision-making concept typical of NCLEX-style nursing judgment.

Question 8

A patient with dyspnea should be placed in which position?

Accepted Answer

Answer reason: B. Fowler's This position promotes maximal lung expansion by using gravity to lower the diaphragm and reduce pressure from abdominal contents on the thorax. It also decreases the work of breathing and can improve ventilation-perfusion matching, helping relieve shortness of breath. Supine positioning can worsen dyspnea by limiting chest expansion, while Trendelenburg increases venous return and respiratory compromise. Lateral positioning may be used for specific conditions, but it is not the standard first-line positioning to improve breathing effort.
Category reason: This question tests a nursing comfort/safety intervention—positioning a symptomatic patient to improve breathing—rather than underlying biomedical mechanisms, aligning with non-pharmacologic care measures.

Question 9

Scenario: A terminal cancer patient in hospice care is restless and short of breath. What is the nurse’s best response?

Accepted Answer

Answer reason: In hospice, care is goal-directed toward symptom relief rather than life-prolonging or invasive resuscitative measures. Restlessness and dyspnea at end of life are commonly managed first with comfort-focused interventions such as optimizing positioning, providing supplemental oxygen if it eases air hunger, and maintaining a calm environment. Intubation, CPR, or ICU transfer are generally inconsistent with hospice goals and can increase suffering unless specifically aligned with the patient’s expressed wishes.
Category reason: This question tests nursing judgment in end-of-life symptom management and selecting comfort-focused interventions rather than escalated curative treatment, aligning with Basic Care and Comfort—Non-Pharmacological Comfort Interventions.

Question 10

Scenario: A nurse applies an ice pack to a patient’s sprained ankle. What is an important safety precaution?

Accepted Answer

Answer reason: Cold therapy can cause tissue injury such as frostbite, numbness-related unrecognized damage, or impaired circulation, especially if applied too long or with inadequate insulation. Regular skin checks allow early detection of pallor, cyanosis, excessive redness, pain, or blistering so the ice can be removed promptly. Applying ice directly to skin is unsafe, and typical application is closer to 15–20 minutes rather than 30–60 minutes. Elevation is helpful for swelling but does not address the primary safety risk of cold-induced skin injury.
Category reason: This question tests nursing safety during a nonpharmacologic comfort intervention (cold application), focusing on monitoring and preventing complications from therapy, which fits Basic Care and Comfort.

Question 11

Scenario: A post-op patient refuses pain medication due to side effects. What should the nurse do next?

Accepted Answer

Answer reason: Because the client is refusing analgesics due to adverse effects, the nurse should next implement nonpharmacologic pain-relief measures that respect the client’s preference while still addressing comfort. These interventions are low risk and can reduce pain and anxiety, often decreasing the need for medication. Education alone does not treat current pain, and requesting stronger medication is inappropriate when the client is already declining meds. Leaving the client without offering alternatives fails to address an immediate comfort need.
Category reason: This is a patient-care decision about managing postoperative pain using nursing interventions, aligning with Basic Care and Comfort—Non-Pharmacological Comfort Interventions.

Question 12

A client with pericarditis reports chest pain that worsens with lying down and deep breathing. Which position relieves discomfort?

Accepted Answer

Answer reason: Leaning forward decreases pericardial contact and reduces stretch/pressure on the inflamed pericardium, which typically lessens pleuritic, positional pain. Pericarditis pain classically worsens when supine and improves when sitting up and leaning forward. This position is a rapid, nonpharmacologic comfort measure while further evaluation and anti-inflammatory therapy are arranged.
Category reason: This item asks the nurse to choose a positioning intervention to relieve a symptom (pain) in a client with pericarditis, which is a nonpharmacologic comfort measure within patient care.

Question 13

Scenario: A 5-year-old is admitted with a fractured arm and is crying. What tool is best for assessing pain level in this child?

Accepted Answer

Answer reason: A 5-year-old can typically self-report pain using age-appropriate visual tools. The faces scale is validated for young children and is easy to understand even when distressed or crying. Numeric and verbal descriptor scales require more advanced cognitive/communication skills and are more reliable in older children. FLACC is observational and is preferred when the child cannot reliably self-report (e.g., preverbal, sedated, or developmentally unable).
Category reason: This question tests selection of an appropriate nursing pain assessment tool for a pediatric patient, which is a patient-care comfort assessment/intervention decision rather than foundational biomedical knowledge.

Question 14

A patient with pericarditis reports sharp chest pain that increases when lying flat. What nursing intervention is most appropriate?

Accepted Answer

Answer reason: Pericarditis pain is classically pleuritic and positional, worsening when supine and improving when the torso is upright and leaning forward because this reduces pericardial irritation and contact. Elevating the head of bed is a safe, immediate nonpharmacologic intervention that can decrease pain while further assessment and provider-directed therapy (e.g., NSAIDs) are arranged. Nitroglycerin targets ischemic chest pain and is not the first-line nursing response for pericarditic pain. Reassurance alone is insufficient, and cold compresses are not an evidence-based primary intervention for this condition.
Category reason: This item tests a nursing comfort intervention (positioning) to reduce symptoms in a patient-care scenario, which fits NCLEX Basic Care and Comfort rather than foundational biomedical science.

Question 15

The nurse is caring for a client with acute pancreatitis. What is the most comfortable position?

Accepted Answer

Answer reason: C. Side-lying with knees to chest (fetal position) This position flexes the trunk and can reduce stretching/pressure on the inflamed pancreas and surrounding peritoneal tissues, which helps decrease pain. It often improves comfort by minimizing abdominal muscle tension and promoting a sense of support to the abdomen. Supine and prone positions can increase discomfort by placing pressure on the abdomen and may worsen pain, while High Fowler’s may help some clients but is typically less relieving than the knee-chest side-lying posture in acute pancreatitis.
Category reason: This item asks the nurse to choose a patient position to maximize comfort in an acute pain condition, which is a bedside, non-pharmacologic comfort intervention rather than foundational science.

Question 16

Which nursing intervention is best for a newborn with neonatal abstinence syndrome?

Accepted Answer

Answer reason: Neonatal abstinence syndrome commonly causes irritability, jitteriness, hypertonia, and difficulty self-soothing from autonomic overactivity. Decreasing environmental stimuli and providing containment (e.g., swaddling) reduces excessive sensory input and helps organize the infant’s behavior, improving sleep and feeding. Frequent stimulation and bright lights worsen symptoms by increasing arousal and stress. Breastfeeding is generally encouraged when not contraindicated (e.g., ongoing illicit drug use or specific maternal infections), so routinely switching to formula is not the best general intervention.
Category reason: This item tests a nursing comfort/safety intervention (environmental modification and soothing measures) for a symptomatic newborn, which is a patient-care decision within nonpharmacologic nursing management.

Question 17

A laboring mother is 6 cm dilated and reports intense back pain. The fetus is in occiput posterior position. What is the nurse’s best intervention?

Accepted Answer

Answer reason: Occiput posterior positioning commonly causes significant “back labor” due to fetal head pressure against the maternal sacrum. Firm sacral counter-pressure is a safe, immediate, nonpharmacologic comfort measure that can markedly reduce pain during contractions and supports maternal coping. Supine positioning can worsen discomfort and reduce uteroplacental perfusion; IV fluids do not address the pain source. Cesarean birth is not the first-line response at 6 cm dilation without evidence of fetal/maternal compromise or arrest of labor.
Category reason: This item tests a nursing comfort intervention during labor (managing back labor pain) rather than underlying anatomy/physiology, so it fits NCLEX Basic Care and Comfort—Non-Pharmacological Comfort Interventions.

Question 18

Scenario: A 6-month-old baby has a low-grade fever and swelling at the DPT injection site. Q. What advice should the nurse give the mother?

Accepted Answer

Answer reason: These are common, mild post-immunization reactions that can be managed with comfort measures and antipyretic/analgesic therapy. Local warmth can help relieve swelling and tenderness, and acetaminophen helps reduce fever and discomfort. There are no signs of anaphylaxis or severe reaction requiring emergency care (e.g., respiratory distress, facial swelling, hypotension). Mild local reactions are not a contraindication to future vaccinations, so revaccination immediately or stopping vaccines is inappropriate.
Category reason: This question tests nursing guidance for managing a routine post-vaccination reaction using comfort and symptom-relief interventions, aligning with Basic Care and Comfort (Non-Pharmacological Comfort Interventions).

Question 19

A client with suspected peritonitis is reporting severe abdominal pain and guarding. What position provides the most comfort?

Accepted Answer

Answer reason: B. Semi-Fowler's with knees flexed This position decreases tension on the inflamed peritoneum by reducing stretching of abdominal muscles, which helps relieve pain and guarding. Flexing the knees relaxes the abdominal wall and can reduce pressure from intra-abdominal contents. Flat supine tends to increase peritoneal stretch and discomfort, and Trendelenburg can worsen respiratory mechanics and increase discomfort. High Fowler’s may increase gravitational pull and abdominal strain compared with semi-Fowler’s with knee flexion.
Category reason: This item tests a nursing comfort intervention (therapeutic positioning) to reduce pain in a client with suspected peritonitis, which fits Basic Care and Comfort.

Question 20

What is the best method to evaluate the effectiveness of pain management in a client with a fracture?

Accepted Answer

Answer reason: Pain is a subjective experience, so the most valid evaluation of analgesic effectiveness is the patient’s self-report using a standardized tool. A numeric rating scale allows consistent reassessment over time and supports titration of interventions based on the patient’s reported relief. Facial expressions and vital signs can be influenced by anxiety, medications, and other stressors and are not reliable stand-alone measures. Asking if more medication is desired does not quantify pain intensity or response to prior treatment.
Category reason: This question tests nursing evaluation of a comfort intervention (pain management) using an appropriate assessment tool, which fits NCLEX patient-care decision-making in Basic Care and Comfort.

Question 21

Which of the following interventions is helpful in reducing the effects of GERD?

Accepted Answer

Answer reason: GERD symptoms worsen when gastric contents reflux into the esophagus, which is promoted by a supine position and increased intra-abdominal pressure. Head-of-bed elevation uses gravity to reduce nocturnal reflux and esophageal acid exposure, making it an effective nonpharmacologic measure. Lying down after meals increases reflux by removing the gravitational barrier. Tight garments and large fluid intake close to bedtime can increase gastric volume/pressure and aggravate reflux rather than relieve it.

Question 22

A nurse is caring for a 2-year-old child who has pneumonia and a temperature of 39.4° C (103° F). Which of the following actions should the nurse take?

Accepted Answer

Answer reason: Cooling the environment is a reasonable nonpharmacologic intervention that can help promote heat loss without provoking shivering or causing rapid temperature shifts. Aspirin is avoided in children due to the risk of Reye syndrome, especially during viral illnesses that can mimic or coexist with pneumonia. An ice bath is overly aggressive and can trigger vasoconstriction and shivering, potentially worsening oxygen consumption. The listed acetaminophen regimen is inappropriate because 500 mg every 2 hours exceeds safe pediatric dosing intervals and typical weight-based limits, risking hepatotoxicity.

Question 23

A nurse is reinforcing discharge teaching with a parent of a child who has varicella zoster. Which of the following instructions should the nurse include in the teaching?

Accepted Answer

Answer reason: " Varicella causes intensely pruritic vesicular lesions, and care focuses on reducing itching while protecting skin integrity to prevent excoriation and secondary bacterial infection. A topical antipruritic such as calamine is an appropriate home-care comfort measure and is commonly included in discharge teaching. Aspirin is contraindicated in children with viral illnesses due to the risk of Reye syndrome. Keeping the child warm can worsen pruritus, and the description of rash progression is not a key home-care instruction for zoster-focused teaching.

Question 24

The nurse reviews dietary guidelines with a client diagnosed with gastroesophageal reflux disease (GERD). The nurse determines teaching is successful if the client states which of the following?

Accepted Answer

Answer reason: ” GERD symptoms improve with positioning that reduces reflux by using gravity and minimizing gastric contents moving into the esophagus. Head-of-bed elevation (about 6–12 inches) is a standard nonpharmacologic strategy to decrease nocturnal reflux. Left-side sleeping can further reduce reflux episodes compared with right-side positioning due to stomach anatomy and LES exposure to acid. In contrast, peppermint can relax the lower esophageal sphincter and worsen reflux, and tomato juice is acidic like orange juice and may trigger symptoms.

Question 25

The LPN/LVN cares for a client diagnosed with ureterolithiasis. Which of the following actions should the LPN/LVN take FIRST?

Accepted Answer

Answer reason: Ureterolithiasis commonly causes acute renal colic, and uncontrolled pain can rapidly escalate sympathetic stress, nausea/vomiting, and inability to participate in needed care. The first priority is to relieve pain promptly with prescribed analgesics, which is both humane and stabilizes the patient for subsequent interventions. Straining urine is important for stone analysis but does not address the immediate physiologic distress. Cranberry juice is aimed at UTI prevention and is not an acute priority for ureteral stones, and high Fowler’s positioning does not target the underlying pain mechanism.

Question 26

The ideal roller bandage application for body parts where the thickness varies, such as over the forearm, is ?

Accepted Answer

Answer reason: The reverse spiral uses periodic turns (reverses) to accommodate changes in limb circumference, preventing gapping and slippage as the bandage ascends. This makes it ideal for areas like the forearm or calf where diameter changes progressively. In contrast, a simple spiral is best for uniform circumference and tends to loosen or create gaps on conical shapes, increasing risk of impaired support or uneven compression.

Question 27

A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is?

Accepted Answer

Answer reason: With renal calculi, the hallmark complaint is severe flank pain from ureteral spasm/obstruction, so the most immediate, patient-centered outcome is to reduce pain to a tolerable level. Nausea is important but is commonly secondary to the pain and typically improves once analgesia is effective. A low-grade fever warrants monitoring for infection/obstruction complications, but the immediate priority goal in this presentation is comfort and stabilization through prompt pain control.

Question 28

During the acute stage of meningitis, a 3-year old child is restless and irritable. Which of the following would be most appropriate to institute?

Accepted Answer

Answer reason: A quiet, dim, low-traffic environment helps reduce agitation and can help prevent increases in intracranial pressure triggered by stress and excessive sensory input. In contrast, limiting conversation is less effective than globally reducing stimulation and can undermine reassurance and assessment. Allowing bathtub play increases activity and can be unsafe in an acutely ill child, and rushing treatments can heighten anxiety and stimulation rather than provide comfort.

Question 29

What is the highest nursing priority outcome when planning the care for the patient with pancreatitis?

Accepted Answer

Answer reason: Acute pancreatitis typically causes severe abdominal pain, and uncontrolled pain drives sympathetic stress responses that can worsen respiratory effort, limit mobility, and impede participation in care. Prioritizing effective pain control supports adequate ventilation, enables early activity as tolerated, and facilitates nutritional and fluid management plans. Compared with discharge teaching or bowel pattern, pain relief addresses an immediate physiologic need and is a central marker of stabilization in the acute phase. Education and functional tolerance are important later outcomes, but they depend on the patient first being comfortable enough to engage and recover safely.

Question 30

The nurse is taking care of a pediatric client after an asthma attack. To promote comfort, the nurse instructs the client to assume which position?

Accepted Answer

Answer reason: Upright positioning maximizes lung expansion and decreases work of breathing by improving diaphragmatic excursion and ventilation. After an asthma attack, sitting high Fowler’s can help relieve dyspnea and facilitate use of accessory muscles without compressing the chest. Supine/dorsal positioning can worsen ventilation by limiting chest expansion and promoting fatigue. Prone and side-lying may be used in other respiratory situations but are not the most consistently comfortable and airway-opening posture for a child recovering from bronchospasm.

Question 31

When caring for a male patient who has just had a total laryngectomy, the nurse should plan to?

Accepted Answer

Answer reason: This includes providing tools such as writing materials, picture/communication boards, or an electrolarynx when appropriate, and teaching staff and family how to use them. Early oral feeding is not appropriate because swallowing may be impaired and aspiration risk is a concern until evaluated and cleared. Keeping the cuff fully inflated is not a routine goal (it can increase tracheal mucosal injury), and positioning flat increases aspiration/airway secretion management problems rather than promoting recovery.

Question 32

The nurse is teaching a male client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching?

Accepted Answer

Answer reason: Breathing retraining in chronic bronchitis aims to reduce the work of breathing and improve ventilation efficiency by maximizing diaphragmatic excursion and limiting accessory muscle use. This technique promotes better alveolar ventilation and can decrease dyspnea during exertion in obstructive lung disease. Making inhalation longer than exhalation can worsen air trapping; patients with obstructive disease generally benefit from a longer, controlled exhalation. Exhaling through an open mouth is nonspecific and does not provide the back-pressure benefits used to prevent airway collapse, while chest breathing increases accessory muscle work and fatigue.

Question 33

One of the most critical needs of the infant is control of body temperature. The nurse caring for a newborn warms all equipment that come in direct contact with the newborn and warms her hands before touching the newborn. This help prevent which type of heat loss?

Accepted Answer

Answer reason: Cold equipment or hands touching a newborn pulls heat away from the infant’s skin into the cooler object, which is direct-contact heat loss. Warming items that will touch the newborn reduces the temperature gradient and therefore reduces this transfer. Convection instead involves air currents, and evaporation involves moisture on the skin, so those are not the primary issue described.

Question 34

The LPN is caring for a 1 month old patient that just had surgery. In order to evaluate post op pain, the nurse will expect to use which pain scale?

Accepted Answer

Answer reason: The FLACC scale (Face, Legs, Activity, Cry, Consolability) is validated for assessing acute pain in nonverbal children, including infants, making it appropriate for a 1-month-old post-op patient. Self-report scales like 0–10 and Wong-Baker FACES require developmental ability to understand and communicate pain intensity and are better suited to older children. Oucher is also intended for older children who can self-report using pictures or numbers, not newborns.

Question 35

The nurse teaches the client relaxation techniques and guided imagery as an adjunct to medication for treatment of pain. What is the main rationale for the use of these techniques as an adjunct to analgesic medication?

Accepted Answer

Answer reason: Nonpharmacologic pain management can reduce the perceived intensity of pain by modulating attention, anxiety, and the cognitive appraisal of pain, which lowers overall analgesic requirements. When these techniques improve comfort, the client may achieve adequate pain control with smaller medication doses, decreasing risks such as sedation, constipation, nausea, respiratory depression, or dependency. Cost and convenience may be secondary benefits, but they are not the primary clinical rationale for combining these approaches with analgesics. Self-injection is irrelevant because many analgesics are oral, topical, or clinician-administered, and the goal is symptom relief with minimized medication burden.

Question 36

The nurse is caring for a client with renal calculi. Which health care provider order would be a priority?

Accepted Answer

Answer reason: Opioid analgesia is appropriate for severe pain and PCA allows timely titration based on patient need while maintaining safety parameters. Hydration and keeping the IV line patent are important for facilitating stone passage and potential procedures, but they do not address the most immediate threat to comfort and function. Warm compresses can be adjunctive but are insufficient for severe renal colic, and IV antibiotics are only prioritized when infection is suspected (e.g., fever, pyuria, sepsis risk), which is not indicated in the stem.

Question 37

The nurse is assessing a newborn the day after birth. A high pitched cry, irritability and lack of interest in feeding are noted. The mother signed her own discharge against medical advice. What intervention is appropriate nursing care?

Accepted Answer

Answer reason: Minimizing light, noise, and handling decreases autonomic arousal, helps the infant self-regulate, and can improve feeding readiness. Frequent rocking and extra talking add stimulation and can worsen irritability and high-pitched crying. Forcing frequent formula feeds does not address the underlying dysregulation and may increase stress and feeding intolerance if the infant is poorly organized.

Question 38

During a situation of pain management, which statement is a priority to consider for the ethical guidelines of the nurse?

Accepted Answer

Answer reason: Using the client’s report supports beneficence and respect for autonomy and prevents undertreatment due to clinician bias. It also aligns with standards that the patient is the most reliable source for pain intensity when able to communicate. A common error is relying primarily on observations or personal judgments, which can delay relief and violate ethical obligations to provide comfort and minimize suffering.

Question 39

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?

Accepted Answer

Answer reason: The nurse must begin by believing and acknowledging the report, which establishes a therapeutic baseline and prevents undertreatment. Only after this acceptance should the nurse proceed to characterize the pain (location, intensity, quality, timing) and assess coping strategies. Options that start with detailed descriptors or coping methods skip the foundational principle that the client’s report initiates the assessment process.

Question 40

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

Accepted Answer

Answer reason: Warm sitz baths soothe irritated vulvar/perineal tissues and can reduce dysuria by relaxing tissues and diluting urine contact with lesions. Cleansing with soap can be irritating and drying to inflamed mucosa, potentially worsening discomfort. Spraying warm water after urination can help dysuria, but sitz baths provide broader, sustained symptom relief and are a common first-line nursing comfort intervention. Heat/cold application is less standardized for this area and may be uncomfortable or impractical compared with sitz baths.

Question 41

A client complains of some discomfort after a below the knee amputation. Which action by the nurse is appropriate to do Initially?

Accepted Answer

Answer reason: Using distraction or guided imagery can decrease pain perception, anxiety, and sympathetic arousal while the nurse continues assessment and prepares additional interventions if needed. Elevation of a below-knee stump beyond the immediate postoperative period can contribute to hip flexion contracture risk and is not the primary initial comfort action. Opioids may be needed, but starting with a safe, rapid nonpharmacologic method is an appropriate initial nursing step while confirming pain characteristics and monitoring for adverse effects.

Question 42

A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the client's comfort?

Accepted Answer

Answer reason: Brief interactions allow the client to rest and reduce dyspnea and tachypnea that can worsen with prolonged talking. This intervention is immediately supportive and can be implemented regardless of disease severity. In contrast, frequent vital-sign checks are monitoring-focused and may interrupt rest, and increased fluids are helpful for secretion mobilization but are not as directly targeted to immediate comfort.

Question 43

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: Cool mist/humidified air can help loosen secretions and decrease mucosal dryness that worsens coughing and stridor, while adequate fluids prevent dehydration from tachypnea and poor intake. Antibiotics are not indicated unless bacterial infection is suspected, which is not typical of spasmodic/viral croup. Sedation and antihistamines can depress respiratory drive or dry secretions, potentially worsening airway obstruction and are not first-line home management.

Question 44

The nurse is teaching a client newly diagnosed with asthma how to use the metered-dose inhaler (MDI). The client asks when they will know the canister is empty. The best response is?

Accepted Answer

Answer reason: The accurate, safe method is to track actuations based on the number of doses stated on the label (or use an integrated dose counter) and replace the inhaler when that count is reached. The “float test” is not recommended because buoyancy varies by canister design and can give false reassurance. Estimating doses risks running out unexpectedly, which can lead to poor symptom control or an emergency during an asthma flare.

Question 45

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

Accepted Answer

Answer reason: Characterizing the pain (severity, location, onset, quality, and associated symptoms) helps identify potential urgent causes (e.g., infection, rhabdomyolysis, ischemia, medication adverse effects) and establishes a baseline to evaluate response to therapy. Giving an analgesic first can mask symptoms and delay recognition of a serious condition, especially in older adults with atypical presentations. Reassuring that pain is “normal” for age is unsafe and dismissive, and advising increased activity without assessment could worsen an underlying injury or systemic illness.

Question 46

The nurse plans care to assist the patient with cognitive-behavioral strategies to reduce pain at which time?

Accepted Answer

Answer reason: g., relaxation, guided imagery, distraction) work best when the patient can concentrate and minimize competing stimuli. A quieter environment reduces interruptions and anxiety, improving the patient’s ability to practice techniques correctly and sustain them long enough to achieve analgesic benefit. Waiting until pain is most severe makes it harder to focus and is less effective than implementing strategies proactively. Coordinating teaching/practice when the unit is calm also supports adherence and learning for continued self-management.

Question 47

Which of the following can be use to determine if a prescribed pain management therapy is effective for a non verbal patient?

Accepted Answer

Answer reason: This option provides a structured way to estimate pain intensity from facial expression and behavioral cues and to trend changes after analgesic administration, which is how effectiveness is evaluated. The other tools assess unrelated clinical domains (cervical cancer screening, pressure-injury risk, and neonatal transition status), so they cannot measure response to analgesia. Reassessing with the same tool at appropriate intervals supports objective comparison before and after therapy.

Question 48

A nurse is teaching a client newly diagnosed trigeminal neuralgia. Which of the following client statements indicate that teaching was effective?

Accepted Answer

Answer reason: " Trigeminal neuralgia pain is often triggered by light sensory stimulation to the face or mouth, including temperature extremes. Avoiding hot foods reduces provocation of the trigeminal nerve and helps prevent pain attacks during eating. Cold application such as an ice pack can also trigger attacks in some clients, so it is not universally recommended. Chewing increases jaw movement and oral stimulation, which commonly worsens rather than relieves symptoms.

Question 49

The nurse takes a phone call from a parent of an adolescent with a cast following a tibia fracture. The client's parent indicates that they have excessive itching. The nurse should recommend for the parent to?

Accepted Answer

Answer reason: Itching under a cast is best managed with safe, noninvasive comfort measures that do not compromise skin integrity or the cast. Cool air can reduce pruritus and helps keep the skin dry, lowering irritation risk without introducing moisture or foreign objects. Inserting anything under the cast (even “sterile” items) can abrade skin and create pressure areas that may progress to infection or ulceration. Putting water or creams under the cast can trap moisture, soften skin, and damage the cast padding, increasing risk for breakdown and odor/infection.

Question 50

A patient about to undergo abdominal inspection is best placed in which of the following positions?

Accepted Answer

Answer reason: The supine position (often with a small pillow under the head and knees slightly flexed) reduces voluntary guarding and keeps the abdomen symmetrical for accurate observation of contour, distention, scars, pulsations, or visible peristalsis. Prone and side-lying limit full visualization and can create asymmetry, while Trendelenburg is not a standard position for routine abdominal exam and may increase discomfort or respiratory work.

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