Question 1

The nurse observes the NA caring for the child newly diagnosed with hyperthyroidism. Which action by the NA requires the nurse to intervene?

Accepted Answer

Answer reason: Adding extra blankets can trap heat and worsen tachycardia, restlessness, and dehydration risk, so the nurse should stop and redirect this action. Comfort measures should instead focus on a cool, quiet environment and lightweight clothing/bedding. The other actions are generally appropriate supportive care and do not directly increase physiologic risk in hyperthyroidism.

Question 2

The new nurse is providing teaching to the 12-year-old who is experiencing exophthalmia. Which instruction demonstrates to the supervising nurse that the new nurse lacks understanding of current practices?

Accepted Answer

Answer reason: Forcing the eyelids shut with tape can cause skin breakdown, corneal abrasion, or trap debris/secretions against the eye, and it is not a routine current practice for eye protection in this situation. Safer supportive measures include artificial tears to prevent drying and sunglasses outdoors to reduce wind and light irritation. A darkened environment may be used for comfort with photophobia, but it does not address the key safety issue as directly as avoiding traumatic taping.

Question 3

A client is ready to be discharged after arthroscopic knee surgery. Which instruction should the nurse expect the health care provider to provide?

Accepted Answer

Answer reason: Post-arthroscopy discharge teaching emphasizes edema and pain control while protecting the operated joint. Cryotherapy and elevation decrease local inflammation, swelling, and bleeding/oozing, which improves comfort and supports mobility during early recovery. Minimizing swelling also helps reduce risk of neurovascular compromise from excess tissue pressure. A common misconception is that small incisions eliminate infection risk, but any surgical incision can become infected and still requires monitoring and care.

Question 4

Feedings are being withheld in a neonate with esophageal atresia and tracheoesophageal fistula until a gastrostomy tube can be placed. What is the most appropriate nursing intervention to implement when the neonate is irritable and crying?

Accepted Answer

Answer reason: A neonate who is NPO due to esophageal atresia/TEF still needs comfort measures that do not increase aspiration risk. Non-nutritive sucking via a pacifier provides soothing and helps meet the infant’s sucking drive without delivering oral feedings. Holding or increased stimulation can be helpful, but they are less targeted to the physiologic source of distress (hunger/sucking need) and may increase agitation in some infants. A pacifier is a simple, safe first-line comfort intervention while awaiting gastrostomy placement.

Question 5

Which instruction should the nurse include when teaching parents about the care of a child with chickenpox?

Accepted Answer

Answer reason: Chickenpox causes intensely pruritic vesicular lesions, and the key home-care priority is controlling itching to reduce scratching and secondary bacterial infection. Antipruritics (e.g., topical soothing agents or prescribed antihistamines) directly address discomfort and help protect skin integrity. Routine antibiotics are not indicated unless there is evidence of secondary infection, so empiric penicillin/erythromycin teaching is inappropriate. Children with varicella should avoid contact with other children until no longer contagious, and varicella-zoster immune globulin is reserved for post-exposure prophylaxis in high-risk susceptible individuals rather than routine care teaching.

Question 6

The adult client has a reddened sore throat with white patches that feels like “razor blades when swallowing.” A rapid strep test is negative. Which statement should the nurse make when instructing the client to gargle with saltwater?

Accepted Answer

Answer reason:  Warm saline gargles are a nonpharmacologic comfort measure that helps mechanically cleanse the oropharynx by loosening mucus and debris and promoting oral hydration. This is realistic teaching for a sore throat when bacterial strep is not confirmed, focusing on symptomatic care rather than promising complete pain relief. Claiming it will “take away” pain is too absolute and sets inaccurate expectations. “Distraction from pain” describes a different comfort strategy and is not the primary rationale for saline gargles.

Question 7

Which is the best example of a nurse preventing painful stimuli?

Accepted Answer

Answer reason: Preventing painful stimuli is best achieved by pre-emptive analgesia so pain pathways are blunted before an activity expected to increase discomfort. Using PCA shortly before ambulation anticipates movement-related pain and helps maintain function while avoiding the cycle of escalating pain and guarding. Deep breathing during a painful procedure helps with coping and distraction, but it does not prevent the painful stimulus from occurring. Ice can reduce pain and inflammation, but it is a treatment after pain is present or for localized swelling rather than a clear example of pre-empting an anticipated painful event.

Question 8

A 19-year-old client comes to the clinic with dark red lesions on her hands, wrist, and waistline. She has scratched several of the lesions, and they are open and bleeding. The nurse instructs the client to try pressing on the itchy lesions. The nurse explains that pressing on the skin?

Accepted Answer

Answer reason: Pressing or applying firm pressure to an itchy area can reduce the perception of itch by providing an alternative sensory input that competes with itch signals (sensory “gating”), offering temporary relief. This nonpharmacologic strategy helps the client avoid scratching, which is especially important when lesions are already excoriated and bleeding. Reducing scratching decreases additional skin breakdown and lowers the risk of secondary bacterial infection. Options about spreading microorganisms or causing skin breaks are not the intended therapeutic effect, and while pressure does stimulate nerve endings, the clinically relevant teaching point is to use it as an alternative to scratching.

Question 9

The nurse speaks with the client who recently learned that cataracts are developing in both of the client’s eyes. Which statement made by the client should the nurse correct?

Accepted Answer

Answer reason:  Cataract extraction is typically an elective procedure based on the degree to which vision impairment affects safety and daily functioning, not an automatic urgent surgery. Many clients can delay surgery with monitoring and updated corrective lenses until symptoms significantly interfere with activities (e.g., driving, reading, fall risk). The other statements reflect standard cataract care: surgeries are commonly staged one eye at a time, the opacified natural lens is removed, and an intraocular lens is often implanted during the procedure. The nurse should correct the assumption of urgency and reinforce individualized timing based on functional impact and ophthalmology evaluation.

Question 10

The laboring client is at 5/100/0, RCA, and having difficulty coping with her contractions. She does not want an epidural analgesia or medications. How can the nurse best assist the client and her partner at this time?

Accepted Answer

Answer reason: Back labor is commonly associated with occiput posterior malposition, where the fetal head presses against the maternal sacrum and causes intense pain. Firm sacral counterpressure provides targeted nonpharmacologic pain relief by reducing pressure on sacral nerves and helping the client cope during contractions. At 5 cm with complete effacement, contractions are typically strong and frequent, so a focused, hands-on technique that the partner can perform is especially useful. Effleurage and calming the environment can help relaxation but are often less effective for severe back pain, and breathing techniques alone may not adequately address this pain source.

Question 11

The nurse observes the postpartum multiparous client rubbing her abdomen. When asked if she is having pain, the client says, "It feels like menstrual cramps." Which intervention should the nurse implement?

Accepted Answer

Answer reason: Afterpains are common postpartum uterine contractions, often stronger in multiparous clients, and can feel like menstrual cramps as the uterus involutes. Local heat promotes muscle relaxation and can reduce cramping through nonpharmacologic comfort measures. Prone positioning is not a standard or reliably effective intervention and may be uncomfortable, especially after delivery. While ongoing assessment is important, typical crampy afterpains alone do not specifically indicate hemorrhage, and management should first address expected postpartum discomfort safely.

Question 12

The client has a vaginal delivery of a full-term newborn. Immediately after delivery, the nurse assesses that the client’s perineum and labia are edematous, but she does not have an episiotomy or a perineal laceration. Which intervention should the nurse implement?

Accepted Answer

Answer reason: Immediate postpartum perineal edema is treated first with cold therapy to promote vasoconstriction, decrease capillary permeability, and reduce swelling and pain. Applying an ice pack to the perineum is a safe, effective first-line comfort measure in the first 24 hours after a vaginal birth, even without an episiotomy or laceration. Warm packs are typically introduced later (after the first 24 hours) to increase circulation and promote healing, which can worsen early swelling if used too soon. A donut cushion can increase pressure on the perineum and potentially impair circulation, making it a less appropriate choice for acute edema management.

Question 13

A client in skeletal traction complains of pain and received a dose of an analgesic 1 hour ago. The nurse educates and offers the client an alternative pain-management measure. Which of the following actions should be implemented based on the nurse’s scope of practice?

Accepted Answer

Answer reason: Guided relaxation and imagery are evidence-based techniques that nurses can safely implement without specialized licensure, making them appropriate while analgesics are taking effect. In contrast, modalities such as hypnosis or structured bodywork therapies may require specialized training, credentialing, or institutional credentialing beyond routine RN scope. In a client in traction, selecting a low-risk, non-manipulative technique also avoids disrupting alignment or increasing discomfort.

Question 14

A 20-year-old client is being treated for pneumonia. He has a persistent cough and complains of severe pain when coughing. The most appropriate instruction the nurse would give the client to reduce discomfort is?

Accepted Answer

Answer reason: Splinting supports the thoracic muscles and reduces painful movement of the chest wall during coughing, allowing the client to clear secretions while minimizing discomfort. Effective coughing is important in pneumonia to mobilize and expectorate sputum and prevent atelectasis. Suppressing cough can worsen secretion retention and impair airway clearance. Flattening the bed and restricting fluids can both hinder respiratory comfort and secretion clearance because upright positioning and adequate hydration help thin and mobilize mucus.

Question 15

A client is complaining of pain rated an 8 out of 10 on the numeric pain scale. The nurse administers an oral pain medication to the client and starts a CD of the client’s favorite relaxing music. Fifteen minutes later, the client rates the pain as 2 out of 10 on the numeric pain scale. What type of nonpharmacologic pain relief intervention has the nurse used?

Accepted Answer

Answer reason: Nonpharmacologic pain management can reduce perceived pain by shifting the patient’s attention away from the painful stimulus and decreasing anxiety. Playing the client’s favorite relaxing music is a classic cognitive-behavioral technique that occupies attention and alters pain perception. Biofeedback would require monitoring physiologic signals and teaching the client to control them, which is not described. Progressive relaxation involves guided muscle tensing/relaxing exercises, and cutaneous stimulation involves physical measures like massage, heat/cold, or TENS—neither of which is indicated here.

Question 16

A 19-year-old client presents with second-degree sunburn on her face and both arms. What is the initial intervention by the nurse?

Accepted Answer

Answer reason: Immediate care for superficial partial-thickness (second-degree) sunburn prioritizes stopping the heat injury and decreasing pain and edema. Cool, moist compresses provide rapid nonpharmacologic analgesia and reduce local inflammation without damaging fragile blistered tissue. Sterile dry towels are not the best initial measure for uncomplicated sunburn and can increase discomfort by adhering to weeping areas. Topical vitamin preparations are not first-line and may irritate the skin or trap heat early in the injury.

Question 17

The client asks the nurse what can be done to alleviate the pain and discomfort associated with varicose veins. Which response by the nurse is best?

Accepted Answer

Answer reason:  Varicose vein discomfort is largely driven by venous pooling from incompetent valves, so interventions that improve venous return reduce edema, aching, and heaviness. Graduated compression stockings increase external pressure on superficial veins, improving forward flow and decreasing venous stasis, which directly targets symptom relief. Letting the legs dangle increases dependent venous pressure and typically worsens swelling and pain rather than relieving it. Saying only surgery helps is inaccurate because conservative measures (compression, elevation, activity) are first-line for many clients, and focusing on clothing for appearance does not address pathophysiology or comfort.

Question 18

The client is being seen in the clinic for a second-degree ankle sprain. Which treatments should the nurse plan?

Accepted Answer

Answer reason: Acute ligament sprains are managed initially with RICE to reduce bleeding, edema, and pain while protecting the injured tissues. Intermittent cold therapy and compression limit inflammatory swelling, and elevation promotes venous/lymphatic return. Heat and early aggressive range-of-motion can increase vasodilation and swelling in the acute phase, worsening pain and tissue injury. Routine referral to orthopedics is not the standard first-line plan for an uncomplicated second-degree sprain; initial conservative care and reassessment are appropriate.

Question 19

After determining that the client with CRF has no signs of an infection, the nurse initiates the first peritoneal dialysis treatment for the client. During the infusion of the dialysate, the client reports abdominal pain. How should the nurse best respond to the situation?

Accepted Answer

Answer reason: Abdominal pain during inflow in an initial peritoneal dialysis exchange is commonly related to peritoneal stretching and increased intra-abdominal pressure rather than infection when no signs of peritonitis are present. Elevating the head of the bed helps the dialysate distribute more comfortably in the abdomen and can reduce diaphragmatic pressure and discomfort. This intervention is immediate, noninvasive, and maintains the prescribed therapy without interrupting the exchange. Stopping the infusion is typically reserved for severe pain or suspicion of complications (e.g., catheter malposition, peritonitis), which is not supported by the scenario.

Question 20

A client was prescribed an anti-inflammatory drug for osteoarthritis 5 days ago. The client says the pain has decreased a little but not completely. Which of the following nursing interventions would be the most appropriate?

Accepted Answer

Answer reason: Analgesic and anti-inflammatory therapies for chronic osteoarthritis often require time to reach a stable therapeutic effect, and partial improvement after several days is not unexpected. The safest nursing action is to continue the current regimen as prescribed while supporting comfort with adjunct measures such as heat/cold, rest–activity pacing, positioning, and gentle exercise as tolerated. Escalating dose or adding medications introduces increased risk (e.g., GI bleeding, renal effects) and requires provider evaluation, especially so early in therapy. Stopping the medication is not indicated when there is some benefit and no adverse effects reported.

Question 21

A client has an above-the-knee amputation 4 days after a traumatic injury. Which nursing diagnosis is most appropriate?

Accepted Answer

Answer reason: At 4 days post–above-knee amputation, pain (including phantom sensations/pain) is a highly likely, immediate nursing problem that requires assessment and management for comfort and function. The other choices describe complications or conditions (shock, fat embolism, decreased peripheral circulation) that are not inherently expected at day 4 without supporting assessment findings. A nursing diagnosis should reflect the most probable current patient problem based on the clinical context and timeframe.

Question 22

The experienced nurse and the new nurse are preparing to provide phototherapy to the 4-day-old infant with hyperbilirubinemia. Which information should the experienced nurse include when instructing the new nurse about providing phototherapy for the infant?

Accepted Answer

Answer reason: Phototherapy uses high-intensity blue light that can injure an infant’s eyes if direct exposure occurs, so eye protection is a key safety measure. Effective treatment also requires maximal skin exposure; clothing is minimized while thermoregulation is maintained with temperature monitoring and a neutral thermal environment. Adequate hydration and frequent feeding are encouraged because bilirubin is excreted in stool and urine, and increased stools are expected. Mild transient rashes or loose stools can occur and are typically managed with monitoring and skincare rather than stopping therapy unless more serious findings develop.

Question 23

The hospitalized client is at risk for thromboembolism. Which direction should the nurse include when teaching this client about wearing antiembolism hose stockings?

Accepted Answer

Answer reason:  Antiembolism stockings are most effective when applied before venous pooling occurs, which is greatest after standing and during dependent positioning. Putting them on in the morning before getting out of bed helps maintain venous return and reduces stasis-related clot risk. Ambulation decreases risk but does not automatically eliminate the need for prescribed compression therapy in at-risk patients. Pain or skin discomfort should prompt assessment of fit, skin integrity, and circulation rather than routine analgesic use, and leg crossing should be avoided because it impedes venous return.

Question 24

The nurse is assessing the client who was just admitted to a surgical unit following abdominal surgery. Which assessment finding requires immediate intervention by the nurse?

Accepted Answer

Answer reason: Postoperative nursing priorities follow ABCs, and compromised oxygenation requires rapid assessment and action to prevent hypoxemia-related deterioration. An SpO2 of 92% in the immediate post-op period suggests inadequate ventilation/atelectasis and warrants immediate interventions such as encouraging deep breathing, using incentive spirometry, repositioning, and escalating oxygen/notification per protocol. The other findings are expected early postoperative patterns: small dark NG blood can be from mucosal irritation, a small new dressing shadow can be monitored/marked, and serosanguineous JP output with the bulb not maintaining suction (round) is important but typically less urgent than airway/breathing compromise. Addressing oxygenation first is the safest and most time-sensitive nursing action.

Question 25

The nurse applies a warm, moist compress to the site where an IV solution has infiltrated. Which response is correct when the client asks the purpose of the compress?

Accepted Answer

Answer reason:  Moist heat causes local vasodilation, which increases circulation to the affected area and supports removal of infiltrated fluid while improving delivery of oxygen and nutrients needed for repair. This helps reduce swelling and promotes comfort and tissue recovery after IV infiltration. In contrast, decreasing metabolic needs is an effect associated with cold therapy, not warmth. Warm compresses are also not used to “stop histamine release,” and numbness is not the primary therapeutic effect of heat in this setting.

Question 26

Which client would most benefit from an integrative medicine health care strategy?

Accepted Answer

Answer reason: Integrative medicine combines evidence-based complementary approaches with conventional care to improve symptom control and functional status, especially in chronic, multifactorial conditions. Chronic fatigue syndrome commonly has persistent symptoms despite standard therapies, and nonpharmacologic strategies (e.g., sleep hygiene, stress reduction, graded activity pacing, mind-body interventions) can be useful adjuncts. In contrast, uncontrolled diabetes with medication refusal requires urgent adherence/safety-focused management rather than substituting complementary methods. Suspected acute infection with high fever and pleuritic chest pain and acute cholecystitis needing definitive treatment are situations where delaying standard evaluation/treatment increases risk and is not primarily addressed by integrative strategies.

Question 27

A client is postoperative day one after a thoracotomy. The client complains of incisional pain. Vital signs are: temperature 100.9F (38.3C), heart rate 94 beats/minute, blood pressure 138/90 mm Hg, and respirations 22 breaths/minute. Physical assessment reveals shallow respirations and rhonchi at the bases. Which intervention should the nurse perform first?

Accepted Answer

Answer reason: Uncontrolled postoperative pain leads to splinting with shallow respirations, ineffective cough, secretion retention, and atelectasis, increasing risk for pneumonia after thoracotomy. Treating pain first enables the client to take deeper breaths and cough more effectively to clear rhonchi and improve ventilation. Coughing/deep breathing or getting into a chair are important, but they are less effective and may be poorly tolerated if pain is not addressed. The low-grade fever on postoperative day 1 is commonly from atelectasis and is best managed by improving lung expansion rather than prioritizing antipyretics.

Question 28

The client diagnosed with von Willebrand's disease calls a clinic after experiencing hemarthrosis. The client states that factor concentrate is infusing. Which intervention should the nurse recommend now?

Accepted Answer

Answer reason: " Acute hemarthrosis is managed with measures that limit ongoing bleeding and reduce pain and swelling. Local cold causes vasoconstriction and decreases inflammatory edema, which is appropriate while clotting factor is being infused. Aspirin is contraindicated because it inhibits platelet function and can worsen bleeding. Fresh frozen plasma is not the immediate self-care recommendation here when factor concentrate is already infusing and the priority is symptom control and bleeding limitation.

Question 29

A nurse is caring for a breastfeeding client who delivered by cesarean section. What is the most important information for the nurse to teach the client?

Accepted Answer

Answer reason: After cesarean birth, minimizing pressure on the abdominal incision supports comfort and helps the parent maintain effective positioning for latch and milk transfer. The football/clutch hold keeps the infant’s body and feet away from the abdomen and allows better control of the infant’s head while protecting the incision. In contrast, the cradle hold commonly places the infant’s weight across the abdomen, increasing pain and discouraging frequent feeds. Delaying initiation is unnecessary, and the most important early teaching is a safe, comfortable position that supports continued breastfeeding.

Question 30

The client recently diagnosed with glaucoma tells the nurse, “I’m having difficulty remembering to insert my eye drops. I don’t have any pain or vision changes when I forget them.” Which statement is the best response?

Accepted Answer

Answer reason:  The core nursing principle is to promote safe, effective self-management by using practical adherence strategies tailored to the client’s routine. Glaucoma is often asymptomatic early, so the absence of pain or immediate vision change can reduce motivation, making habit-building interventions especially important. Linking drops to an existing daily activity (e.g., brushing teeth) is a concrete cueing method that improves consistency and reduces missed doses. In contrast, fear-based threats or vague reassurance do not equip the client with a workable plan to prevent progressive, irreversible optic nerve damage.

Question 31

The nurse completed teaching on care at home to the mother of a child post-tonsil and adenoidectomy (T&A) surgery. The nurse determines that the mother understands the instructions when the mother makes which statement?

Accepted Answer

Answer reason: Post-tonsillectomy home care prioritizes comfort while monitoring for bleeding, a key complication. Cold fluids/ice pops help reduce throat pain and can decrease local swelling/oozing through vasoconstriction. Avoiding red-colored foods and drinks prevents confusion if the child vomits or spits, since red can mimic fresh blood and delay recognition of true hemorrhage. Other statements promote actions (gargling, hard toothbrush, forceful coughing) that can irritate the surgical site and increase bleeding risk.

Question 32

The client reports pain in the right leg even though it was amputated. Which complementary therapy should the nurse use to control the phantom pain associated with the client’s amputation?

Accepted Answer

Answer reason: Relaxation training is an accepted complementary approach that can be taught and reinforced by nursing to improve coping and decrease perceived pain intensity. The other choices focus on adding anxiolytics or bowel-prevention measures, which do not directly address phantom pain through a complementary modality. A nerve block is an invasive analgesic procedure rather than a complementary therapy and is not primarily a nursing-implemented comfort intervention.

Question 33

A client arrives in the physician’s office complaining of insomnia, decreased appetite, and weight loss due to a recent job loss. The physician diagnoses the client with generalized anxiety disorder and prescribes two common antianxiety medications. The client expresses concern to the nurse about taking medication for the symptoms and asks about alternatives for treating the anxiety. The nurse’s best action is to?

Accepted Answer

Answer reason: Nursing care for anxiety includes teaching and reinforcing evidence-based nonpharmacologic coping strategies tailored to the client’s preferences to improve adherence and effectiveness. Offering a range of relaxation methods (e.g., deep breathing, progressive muscle relaxation, guided imagery, mindfulness) supports patient-centered care and shared decision-making when the client is hesitant about medication. This approach also allows the nurse to assess readiness, barriers, and past experiences to select a realistic strategy the client will actually use. A single prescriptive suggestion (like one specific technique or yoga classes) is less individualized and may not fit the client’s comfort level, resources, or symptom pattern, and referral for finances does not directly address anxiety management skills.

Question 34

A client is having a CAT scan and is worried about being in an enclosed space for the test. The client also states that antianxiety medications cause confusion. The client asks if there are other ways of helping control the fear while the scan is being done. The client reports attending yoga classes and finds guided imagery very relaxing. What is the nurse’s best action to take with this client?

Accepted Answer

Answer reason: Nonpharmacologic anxiety-reduction strategies are appropriate when a client cannot tolerate anxiolytics and must remain still during a confined procedure. Building on the client’s established coping skills (breathing techniques and guided relaxation) increases likelihood of effective self-control and cooperation during the scan. Offering music via headphones is a practical, commonly available comfort measure in radiology that can reduce sensory stress and claustrophobia without interfering with the test. Other options introduce less evidence-based or less immediately feasible modalities for a CT setting, and dietary approaches are not relevant to acute procedural anxiety management.

Question 35

A client arrives at the physician’s office with a history of heart failure, coronary artery disease, fibromyalgia and hypertension. The client complains of weight gain of 5 pounds in the past week with ankle swelling. The client also reports unresolved pain in the neck, back, shoulders, hips, and knees despite the alternated use of ibuprofen and acetaminophen for pain. The pain has led to feelings of constant fatigue and anxiety. Vital signs are: 130/85-75-24-36.0 degrees centigrade. The physician prescribes additional furosemide (Lasix) and potassium (K-dur) and adds carvedilol (Coreg) to the client’s medication regimen. What suggestion should the nurse make to the physician that would be most helpful in resolving the symptoms listed above which were not addressed by the physician?

Accepted Answer

Answer reason: Uncontrolled widespread musculoskeletal pain with associated fatigue and anxiety suggests inadequate chronic pain management, which commonly requires a multimodal plan beyond alternating OTC NSAIDs and acetaminophen. A pain specialist can evaluate for fibromyalgia-directed therapies (e.g., neuropathic pain agents, sleep optimization, graded activity, and behavioral strategies) and coordinate nonpharmacologic interventions while minimizing harm. This is especially important because NSAIDs can worsen fluid retention and blood pressure and may exacerbate heart failure symptoms. Cardiology input may help optimize HF/CAD therapy, but it does not directly address the primary unresolved symptom cluster of chronic pain driving fatigue and anxiety. A support group or CAM may be adjuncts, but they are less likely to provide comprehensive, evidence-based pain control and functional restoration.

Question 36

A client is admitted to the hospital with a blood pressure of 85/53 mm Hg and is complaining of light-headedness and near syncope. The client’s current medications include carvedilol (Coreg), amiodarone (Cordarone), warfarin (Coumadin), lanoxin (Digoxin), furosemide (Lasix), potassium (K-Dur), and a daily vitamin. Client also reports using both St. John’s wort and cat’s claw. Based upon this information, what is the nurse’s best action?

Accepted Answer

Answer reason: Herbal supplements can have clinically significant interactions with cardiovascular drugs, and nurses must identify and report these risks promptly. This client is already hypotensive with presyncopal symptoms while taking multiple agents that can lower blood pressure or affect cardiac conduction (e.g., beta-blocker and antiarrhythmic), so an herb that can potentiate cardiovascular effects is a safety concern requiring provider notification. Cat’s claw has potential additive effects with antihypertensive/cardiac medications and can contribute to symptomatic hypotension, fitting the current presentation. In contrast, St. John’s wort is more notable for drug-metabolism interactions (e.g., reducing warfarin effectiveness) rather than directly causing diuretic-related light-headedness as framed.

Question 37

A client is currently under the care of the palliative care service of home health and has been experiencing nausea. What nursing actions will most likely promote comfort in this client?

Accepted Answer

Answer reason: Comfort-focused palliative nursing prioritizes symptom relief using practical pharmacologic and nonpharmacologic measures that reduce nausea triggers and maintain hydration. This option combines appropriate use of ordered antiemetics with frequent oral care and small, bland oral intake strategies that are commonly effective and feasible in home care. Avoiding gastric irritants (e.g., coffee, milk, acidic juices) can lessen nausea and reflux-related discomfort. By contrast, adding pain medication may worsen nausea (especially opioids) and a detailed history may help assessment but does not directly provide immediate comfort measures.

Question 38

A client has recently been transferred to the medical surgical floor from the ICU after sustaining multiple system traumas. The client has been to the operating room three times in the past 5 days and will require more operations in the coming weeks to repair further injuries. The client is very anxious, rates the current pain as 6 out of 10 on the numeric pain scale, and states the pain medication is not very effective. The client is receiving large doses of both intravenous and oral narcotic and nonsteroidal-type analgesics. The nurse discusses the pain further with the client. The client states a willingness to try anything that might help the pain. What pain control intervention would be most appropriate for this client based upon the information provided?

Accepted Answer

Answer reason: Anxiety heightens sympathetic arousal and amplifies pain perception, so nonpharmacologic strategies that reduce muscle tension and autonomic activation can meaningfully improve comfort alongside medications. This client is already receiving large doses of opioids and NSAIDs with limited relief, making a safe adjunct that targets anxiety and tension especially appropriate. Progressive muscle relaxation is a structured technique that decreases physiologic stress responses and can be taught and practiced repeatedly without adding medication risk. Increasing analgesic doses may worsen adverse effects (e.g., sedation, respiratory depression) without addressing the anxiety-driven component of pain, and herbals carry interaction/bleeding risks in a patient facing multiple surgeries.

Question 39

A 76-year-old woman with a history of osteoporosis experienced a right hip fracture and is admitted to the hospital. The client had a total hip replacement. The most important nursing diagnosis for this client would be?

Accepted Answer

Answer reason: Effective pain control enables early ambulation and pulmonary hygiene, reducing complications such as atelectasis, venous thromboembolism, and delayed recovery. While skin integrity risk and self-care limitations are important, they are typically addressed after stabilizing the patient’s immediate comfort and physiologic tolerance for movement and therapy. Nutrition concerns are usually longer-term and do not take priority over immediate postoperative comfort and function.

Question 40

The nurse using healing touch affects a client's pain primarily through?

Accepted Answer

Answer reason: The intervention is intended to modulate this biofield through intentional, gentle hand placement and focused awareness rather than through mechanical tissue manipulation. Massage would primarily work via physical stimulation of soft tissues and circulation, which is a different mechanism than healing touch. Hypnosis is a cognitive-behavioral technique that alters perception and attention, not an energy-based approach. Therefore, the mechanism most consistent with healing touch is its effect on energy fields.

Question 41

The nurse in the pediatric clinic instructs the parent of a preschool client diagnosed with asthma about preventative care. Which statement by the parent indicates to the nurse that further teaching is necessary?

Accepted Answer

Answer reason: " Asthma prevention teaching prioritizes reducing exposure to common triggers such as dust mites and airborne particulates. Vacuuming aerosolizes dust and allergens, so the child should be kept out of the area (and ideally the home) during and shortly after cleaning rather than relying on a mask, which may not seal well or filter adequately for allergens and can increase breathing discomfort in a preschooler. Using zippered allergen covers and changing clothes after outdoor play are appropriate trigger-reduction strategies. A common safer alternative is using a HEPA-filter vacuum and wet-dusting, with the child away from the environment while cleaning occurs.

Question 42

Patient is suffering from dyspnoea. Which position will you provide for patient to relieve?

Accepted Answer

Answer reason: Fowler’s position elevates the head of bed, allowing the diaphragm to descend more effectively and improving ventilation. It can also reduce venous return and pulmonary congestion, which helps many patients who feel short of breath. In contrast, supine and Trendelenburg positions tend to worsen dyspnea by limiting lung expansion and increasing diaphragmatic pressure; prone is not typically used as an immediate comfort position for an awake dyspneic patient.

Question 43

A client had an episiotomy and complains of perineal discomfort. She is also afraid to have a bowel movement. Which of the following nursing diagnoses is the highest priority for this client at this time?

Accepted Answer

Answer reason: Post-episiotomy discomfort can limit ambulation, sleep, and self-care and it can precipitate fear-avoidance behaviors around toileting. Addressing comfort (e.g., perineal ice packs initially, sitz baths later, positioning, and prescribed analgesics) also supports the client’s ability to relax the pelvic floor and attempt defecation. In contrast, constipation is only a risk at this point and knowledge deficits can be addressed after stabilizing the current symptom burden.

Question 44

A client with emphysema experiences acute shortness of breath. The nurse assists the client into which position?

Accepted Answer

Answer reason: The tripod/forward-leaning upright posture optimizes diaphragmatic excursion, reduces work of breathing, and allows accessory muscles to assist more effectively, which can relieve dyspnea quickly. Supine and side-lying positions can worsen ventilation by limiting chest expansion and increasing diaphragmatic load. Leaning back in a recliner is typically less effective than forward-leaning for maximizing expiratory airflow and easing air trapping.

Question 45

A client with emphysema experiences acute shortness of breath. The nurse assists the client into which position?

Accepted Answer

Answer reason: The forward-leaning “tripod” posture increases thoracic expansion and reduces work of breathing, which is especially beneficial in emphysema/COPD with air trapping. Supine positioning can worsen ventilation by decreasing lung volumes and diaphragmatic movement. A reclined or side-lying position generally provides less immediate ventilatory advantage than upright, forward-leaning positioning during acute shortness of breath.

Question 46

The nurse is preparing a client for a clinical breast exam by the physician. To facilitate an effective exam, the nurse should position the client?

Accepted Answer

Answer reason: Proper positioning for a clinical breast exam should flatten the breast tissue and expose the axillary tail to allow systematic palpation. Raising the ipsilateral arm places the pectoral muscles on stretch and improves access to lateral breast tissue and axilla. A small pillow under the shoulder on the side being examined rotates the torso slightly and spreads breast tissue more evenly across the chest wall, making masses easier to detect. Options that keep arms at the side or use side-lying/sitting postures do not optimize breast flattening and axillary assessment for a standard supine palpation sequence.

Question 47

A nurse applies an ice pack to a client’s leg for 20 minutes. What clinical indicator helps the nurse determine the effectiveness of the treatment?

Accepted Answer

Answer reason: An effective response to a 15–20 minute ice application is reduced pain/sensation in the treated area consistent with localized anesthesia. Peripheral vasodilation is not the expected primary effect of cold; cold initially causes vasoconstriction (any later reactive vasodilation is not the key effectiveness indicator). Cold does not decrease blood viscosity, and systemic vital-sign depression is not an expected or desired outcome from a local ice pack.

Question 48

An 86-year-old client has sustained a fractured femur and has had surgery to repair the fracture. The client is rubbing the surgical site and moaning. Which of the following is the priority nursing intervention?

Accepted Answer

Answer reason: Moaning and guarding suggest pain, but the nurse should first quantify intensity, location, quality, and contributing factors to guide safe, effective analgesia and establish a baseline for response. This assessment also helps identify atypical presentations in older adults (e.g., delirium, oversedation risk, or complications) that could mimic or worsen pain behaviors. Administering medication or checking last dose may be appropriate next steps, but doing so without a current pain assessment can lead to under- or over-treatment.

Question 49

A 32-year-old pregnant client at 30 weeks gestation presents with lower back pain and difficulty sleeping. The nurse performs an assessment and determines that the client patient's discomfort is related to physiological changes associated with pregnancy. What evidence-based interventions should the nurse implement to address the patient's concerns and promote comfort?

Accepted Answer

Answer reason: Late pregnancy shifts the center of gravity and increases lumbar lordosis, making back pain and sleep disruption common; first-line nursing care is nonpharmacologic positioning and ergonomic support. Side-lying (preferably left lateral) reduces aortocaval compression compared with supine positioning and can improve comfort and sleep quality. Lumbar support and pregnancy pillows help maintain spinal alignment and decrease paraspinal strain, while proper body mechanics reduces repetitive mechanical stress that worsens symptoms. Strenuous activity can exacerbate pain and injury risk, and high heels increase lumbar curvature and instability, making them inappropriate for symptom relief.

Question 50

Which of the following represents the most appropriate nursing intervention for a client with pruritis caused by cancer or the treatments?

Accepted Answer

Answer reason: Using smooth, low-friction bedding reduces mechanical irritation during movement and sleep, which can meaningfully decrease itch-related skin breakdown and secondary infection risk. Pharmacologic options like antihistamines are often less effective when itching is not histamine-mediated (common in malignancy- or treatment-related pruritus), and they can add unwanted sedation or anticholinergic effects. Steroids and medicated baths are not universally appropriate first-line nursing measures because they depend on etiology and can worsen dryness or cause further irritation if misused.

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Non-Pharmacological Comfort Interventions NCLEX Practice Test

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The nurse using healing touch affects a client's pain primarily through?

The nurse in the pediatric clinic instructs the parent of a preschool client diagnosed with asthma about preventative care. Which statement by the parent indicates to the nurse that further teaching is necessary?

Patient is suffering from dyspnoea. Which position will you provide for patient to relieve?

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A client with emphysema experiences acute shortness of breath. The nurse assists the client into which position?

A client with emphysema experiences acute shortness of breath. The nurse assists the client into which position?

The nurse is preparing a client for a clinical breast exam by the physician. To facilitate an effective exam, the nurse should position the client?

A nurse applies an ice pack to a client’s leg for 20 minutes. What clinical indicator helps the nurse determine the effectiveness of the treatment?

An 86-year-old client has sustained a fractured femur and has had surgery to repair the fracture. The client is rubbing the surgical site and moaning. Which of the following is the priority nursing intervention?

Which of the following represents the most appropriate nursing intervention for a client with pruritis caused by cancer or the treatments?

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