Question 1

Admitted to the acute psychiatric unit is an older woman with a diagnosis of moderate depression. The client is unclean, her hair is uncombed, and she is inappropriately dressed. Her adult daughter accompanied her who is very upset about her mother's lack of interest in her appearance. Which statement should the nurse appropriately make to alleviate the daughter's concern?

Accepted Answer

Answer reason: e." Moderate depression commonly causes decreased energy, impaired motivation, and psychomotor retardation, which can reduce the patient’s ability to perform activities of daily living. The appropriate nursing response is to reassure the family that the team will provide supportive assistance with hygiene while encouraging gradual return to independence as symptoms improve. The other statements minimize the concern, provide incorrect generalizations, or suggest an unrealistic reliance on peer pressure rather than therapeutic nursing support.
Category reason: The stem centers on a nursing communication and care plan for assisting a depressed inpatient with activities of daily living, specifically hygiene support and progression to self-care—best aligned with Personal Hygiene under Basic Care and Comfort.

Question 2

A client with breast cancer is scheduled for radiation therapy. Which instruction should the nurse provide to protect the skin?

Accepted Answer

Answer reason: Radiation causes skin in the treatment field to become fragile, dry, and prone to irritation and breakdown. Gentle cleansing with mild soap and avoiding scrubbing helps minimize friction and mechanical trauma, reducing the risk of desquamation and infection. Fragranced lotions and adhesive products can further irritate or damage irradiated skin, and sun exposure increases inflammation and hyperpigmentation. Skin-protective care focuses on reducing irritation and maintaining the integrity of the irradiated area.
Category reason: This item tests a nursing intervention for skin protection and hygiene during radiation therapy, which is a patient-care comfort and hygiene measure rather than foundational science.

Question 3

What is the primary goal of oral health assessment?

Accepted Answer

Answer reason: The purpose of an oral health assessment in nursing is to identify the condition of the mouth, teeth, gums, and mucosa to determine hygiene needs and risks such as plaque buildup, gingivitis, caries, mucosal lesions, or halitosis. Findings guide routine and targeted mouth care interventions, patient education, and when to refer to dental or medical providers. While oral findings can sometimes suggest systemic illness, the assessment’s primary nursing focus is evaluating oral cleanliness and tissue integrity rather than diagnosing systemic disease or performing procedures.
Category reason: This item focuses on assessing and maintaining mouth care as a component of routine hygiene, which aligns with nursing care needs under Personal Hygiene within Basic Care and Comfort.

Question 4

A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, "I have been told that it is harmful to bathe during my period." Which action should the nurse take first?

Accepted Answer

Answer reason: Addressing hygiene is an immediate basic care need and can be done while respecting the client’s beliefs and comfort during menstruation. A bed bath promotes cleanliness and reduces odor while offering a less intrusive alternative to showering. Education is appropriate but is not the first priority compared with meeting the immediate self-care need. Simply accepting refusal without offering an acceptable alternative does not support hygiene and comfort.
Category reason: This question centers on a nursing intervention to meet a basic self-care need (hygiene) and determine the first action in patient care, which aligns with Basic Care and Comfort—Personal Hygiene.

Question 5

A patient is unable to perform grooming activities independently. What should the nurse do?

Accepted Answer

Answer reason: C. Assist the patient with grooming while encouraging participation This approach maintains hygiene while promoting independence, dignity, and functional recovery by supporting what the patient can do and assisting only as needed. Encouraging participation helps preserve muscle strength, coordination, and self-efficacy, which can reduce learned helplessness. Ignoring needs risks skin breakdown, infection, and psychosocial distress; doing everything fosters dependency. Delegating to family may be inappropriate or unsafe and does not replace the nurse’s responsibility to assess ability, provide care, and teach adaptive strategies.
Category reason: This is a patient-care intervention question about helping with grooming while promoting independence and comfort, which fits NCLEX Basic Care and Comfort under Personal Hygiene.

Question 6

What is the primary goal of assisting patients with ADL’s?

Accepted Answer

Answer reason: Assisting with activities of daily living aims to maximize independence while supporting safety and comfort. Encouraging the patient to do as much as they can maintains functional ability, preserves dignity, and reduces complications of immobility and deconditioning. Nursing assistance is individualized, progressing from doing-for to coaching and setting up the environment as the patient’s capacity improves.
Category reason: This question focuses on nursing care to support activities of daily living and promote independence, which fits NCLEX patient-care decisions under Basic Care and Comfort.

Question 7

Which of the following is a component of activities of daily living (ADLs)?

Accepted Answer

Answer reason: A. Bathing ADLs are basic self-care tasks necessary for independent functioning, including hygiene, dressing, toileting, feeding, and transferring. Bathing is a core self-care activity commonly assessed to determine a patient’s baseline functional status and need for assistance. The other options are healthcare services/interventions rather than self-care activities performed by the individual.
Category reason: This question tests identification of a basic self-care task within daily patient care, which aligns with nursing-focused Basic Care and Comfort—Personal Hygiene.

Question 8

An elderly client, 84 years old, is unconscious. Assessment of the mouth reveals excessive dryness and presence of sores. Which of the following is BEST to use for oral care?

Accepted Answer

Answer reason: Saline is isotonic and nonirritating, making it appropriate for gently cleansing a dry, sore oral mucosa in an unconscious client. It helps moisten tissues and loosen debris without causing chemical injury or excessive drying. Hydrogen peroxide can damage granulating tissue and further irritate mucosa, while lemon-glycerin swabs are acidic and can worsen dryness and oral irritation. Mineral oil is not ideal for routine oral care and can increase aspiration risk if it reaches the airway.
Category reason: This is a nursing care question about choosing the safest and most appropriate product for providing oral hygiene to an unconscious patient, which fits Basic Care and Comfort (Personal Hygiene).

Question 9

When performing oral care to an unconscious client, which of the following is a special consideration to prevent aspiration of fluids into the lungs?

Accepted Answer

Answer reason: Positioning an unconscious client laterally with the head dependent promotes drainage of oral secretions and rinse water out of the mouth rather than toward the pharynx. This reduces the risk of fluid entering the airway when protective reflexes (gag/cough) are diminished. The other options support hygiene and infection prevention but do not directly reduce aspiration risk during oral care.
Category reason: This item asks for the safest nursing intervention during oral hygiene for an unconscious client to prevent aspiration, which is a bedside care/safety decision within Personal Hygiene.

Question 10

The advantages of oral care for a client include all of the following, EXCEPT:

Accepted Answer

Answer reason: Oral care helps reduce oral bacterial load, supports comfort, and can improve taste perception and appetite by removing debris and reducing halitosis. It also promotes a cleaner appearance that can enhance self-esteem. Avoiding commercial mouthwash is not a standard, universal advantage of oral care; many mouthwashes are optional and some can be drying/irritating, but oral care’s benefits do not depend on reducing their use.
Category reason: This question tests nursing basic care (oral hygiene) and its patient-centered benefits, which fits Personal Hygiene under Basic Care and Comfort.

Question 11

Your client has difficulty of breathing and is mouth breathing most of the time. This causes dryness of the mouth with unpleasant odor. Oral hygiene is recommended for the client and in addition, you will keep the mouth moistened by using?

Accepted Answer

Answer reason: Moistening the oral mucosa for a mouth-breathing client is best done with frequent sips of fluids and regular oral care using water, which hydrates tissues and reduces dryness-related discomfort and halitosis. Petroleum jelly and mentholated ointment are not appropriate for intraoral use and can irritate mucosa or create aspiration risk if applied near the lips/nasal area. Salt solution may be used for rinsing in some situations, but plain water is the safest routine measure for maintaining moisture in this scenario.
Category reason: This item tests a bedside nursing intervention for comfort and hygiene in a symptomatic client (oral moisture management with mouth breathing), which fits NCLEX Basic Care and Comfort—Personal Hygiene.

Question 12

To render comfort measure is one of the priorities, Which includes care of the skin, eyes, ears, mouth and nose. To clean the mouth, your antiseptic solution is in some form of which one below?

Accepted Answer

Answer reason: Oral care commonly uses antiseptic/cleansing solutions formulated to reduce oral microbial load and neutralize acids, helping maintain mucosal integrity and comfort. Alkaline mouth solutions can decrease oral acidity, loosen debris, and support prevention of halitosis and mucosal irritation in routine hygiene care. The other options are not standard categories of antiseptic mouth solutions for routine nursing oral care; water is mainly for rinsing, and sulfur/salt are not typical antiseptic solution forms in this context.
Category reason: This item tests a nursing hygiene intervention (oral care solution selection) as part of comfort measures, which aligns with Personal Hygiene under Basic Care and Comfort.

Question 13

Scenario: A patient’s colostomy site has redness and broken skin at the stoma edge. What is the nurse’s best intervention?

Accepted Answer

Answer reason: Peristomal redness and skin breakdown most commonly result from stool or moisture leakage and adhesive-related irritation, so immediate skin protection and restoration of an effective seal are priorities. A skin barrier product helps protect denuded tissue and promotes healing while the appliance is reapplied correctly to prevent ongoing exposure. Leaving the stoma uncovered increases irritation and infection risk, and simply choosing a larger pouch does not address poor fit at the stoma opening or active skin injury. Surgeon notification is not the first-line action for routine peristomal skin complications that can be managed with ostomy skin care and proper appliance application.
Category reason: This question tests a nursing intervention for skin care and hygiene around a colostomy to prevent further irritation and promote healing, which aligns with Basic Care and Comfort (Personal Hygiene).

Question 14

The nurse notes that the infant is wearing plastic-coated diaper. If a topical medication were to be prescribed and it were to go on the stomach or buttocks, the nurse would teach the caregivers to?

Accepted Answer

Answer reason: Occlusive coverings (including plastic-coated diapers) can increase absorption of topical medications, raising the risk of irritation, skin breakdown, and systemic effects—especially in infants with a higher skin surface area-to-weight ratio. Keeping the medicated area exposed to air when possible helps prevent unintended “occlusion” and allows the medication to act as intended without excess absorption. Options suggesting normal diapering or adding clothing increase occlusion and moisture, while applying an ice pack is not a standard or safe approach for topical medication management in this context.
Category reason: This question tests caregiver teaching about safe application of a prescribed topical medication and diapering practices to prevent skin complications, which is a nursing basic care/personal hygiene intervention.

Question 15

What is the first indication of pressure injury?

Accepted Answer

Answer reason: This change often occurs before skin breakdown and is a key Stage 1 finding that prompts immediate pressure relief and protective measures. Temperature changes (warmth or coolness) can occur, but they are less specific and are usually assessed as supporting cues alongside discoloration. Blotching is not the standard earliest hallmark compared with persistent color change over a bony prominence.

Question 16

The Best position for unconscious patient to provide mouth care is ?

Accepted Answer

Answer reason: A side-lying (lateral) position allows oral secretions and rinse fluid to drain out of the mouth by gravity, reducing aspiration risk. It also facilitates safe suctioning of pooled secretions during mouth care. In contrast, supine or Trendelenburg positions increase the likelihood that fluids will flow toward the posterior pharynx and be aspirated, while high Fowler’s is less protective than lateral positioning if protective reflexes are absent.

Question 17

Which of the following interventions should a nurse perform for a female client who is incontinent with impaired skin integrity?

Accepted Answer

Answer reason: Prompt perineal cleansing after each episode removes irritants, decreases microbial load, and helps maintain an intact moisture barrier to support skin recovery. This is a direct, targeted intervention for impaired skin integrity related to incontinence. Turning every 8 hours is too infrequent for pressure injury prevention and does not address chemical irritation from incontinence.

Question 18

The nurse is planning to administer otic drops to a 6 year-old child. Which of the following is the correct procedure?

Accepted Answer

Answer reason: In children older than 3 years (including a 6-year-old), the pinna should be pulled up and back to align the canal appropriately. Lying should be on the unaffected side so the treated ear faces up, so lying on the affected side would hinder delivery. Routine packing with cotton can obstruct medication flow and may be used only if prescribed and placed loosely, not as a standard step.

Question 19

To prevent keratitis in an unconscious client, the nurse should apply moisturizing ointment to the?

Accepted Answer

Answer reason: Lubricating/moisturizing ophthalmic ointment helps maintain a protective tear film and prevents corneal epithelial breakdown that predisposes to keratitis. This is a basic supportive measure frequently paired with taping the eyelids closed if needed and performing regular eye care assessments. The other listed sites may require routine hygiene, but they do not address the specific risk of corneal drying and subsequent keratitis in an unconscious patient.

Question 20

The nurse is assessing a client with a Stage 2 skin ulcer. Which of the following treatments is most effective to promote healing?

Accepted Answer

Answer reason: Hydrocolloid and foam dressings maintain moisture balance, cushion the area, and protect from shear/friction while absorbing light-to-moderate exudate. Leaving the wound open or using dry dressings increases desiccation and can delay cell migration and granulation. Hydrogen peroxide is cytotoxic to viable tissue and can impair healing, so it is not preferred for routine wound care in this setting.

Question 21

The nurse is caring for a 1 year-old child who has 6 teeth. What is the best way for the nurse to give mouth care to this child?

Accepted Answer

Answer reason: A soft, moistened brush or cloth effectively removes plaque and debris from newly erupted teeth and cleans the gums without irritating tissues. Mouthwash is inappropriate because young children cannot reliably swish and spit and may swallow it, and flavored products can increase ingestion risk. Toothpaste and flossing each tooth is not necessary at this age and increases the chance of swallowing toothpaste while adding little benefit compared with gentle cleaning.

Question 22

A 6 year-old female is diagnosed with recurrent urinary tract infections (UTI). Which one of the following instructions would be best for the nurse to tell the caregiver?

Accepted Answer

Answer reason: Using plain water avoids fragrances and harsh cleansing agents that can disrupt normal vulvar/urethral mucosa and promote inflammation, which can facilitate bacterial ascension. Shampooing hair last prevents soapy water from running down over the perineum during rinsing, further reducing local irritation. Delaying voiding is harmful because urinary stasis increases bacterial growth and infection risk, and antibacterial soaps can be overly drying/irritating rather than protective.

Question 23

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

Accepted Answer

Answer reason: Frequent oral care with a toothsponge removes secretions and debris, hydrates the mucosa, and reduces irritation without requiring swallowing. Ice chips and mints can be contraindicated in the immediate post-op period due to NPO status and aspiration risk after extubation. Glycerin swabs can further dry and irritate the mucosa, so they are not preferred for comfort.

Question 24

The nurse is providing discharge teaching to the parents of a child who just had a high rectal malformation repair. Which of the following discharge instructions should be included in the teaching?

Accepted Answer

Answer reason: Parents must know how to keep the perianal area clean and dry, perform prescribed wound care, and monitor for redness, drainage, fever, or separation of the incision. Promoting soft stools is generally desired to reduce straining and tension on the repair, making the “keep stools firm” option unsafe. Routine enemas are not a standard discharge instruction after this repair unless specifically ordered by the surgeon, because rectal instrumentation can disrupt healing.

Question 25

Type of bandage use for head dressing?

Accepted Answer

Answer reason: A capeline (often spelled capline) bandage is specifically designed for head and scalp dressings, providing circumferential and recurrent turns to hold dressings in place. In contrast, a T-bandage is mainly used to secure perineal/rectal dressings, not head dressings. Spiral and figure-of-eight techniques are generally used for limbs/joints and do not provide the standard secure “cap” coverage needed for the scalp.

Question 26

The nurse is providing perineal care to an uncircumcised client who is in a coma. Which of the following is CORRECT regarding the perineal care?

Accepted Answer

Answer reason: Perineal care follows clean-to-dirty technique to reduce transmission of fecal microorganisms to the urethra and genital skin. Using a separate washcloth for the anal area limits cross-contamination and lowers risk of urinary tract infection and skin breakdown in an immobile, dependent client. In contrast, retracting the foreskin “all the way back” is unsafe if forced and must always be followed by returning it to its normal position to prevent paraphimosis. Sterile saline is not required for routine hygiene; gentle soap and water with appropriate technique is typically sufficient unless otherwise ordered.

Question 27

A nurse is performing an initial assessment on a 75-year-old patient. The nurse asks the patient several questions regarding her ability to perform daily activities. If the nurse was assessing the patient's activities of daily living (ADLs), which question would she ask the patient?

Accepted Answer

Answer reason: " ADLs are basic self-care tasks necessary for independent living, including dressing, bathing, toileting, transferring, continence, and feeding. This question directly assesses the patient’s ability to dress independently, which is a core ADL. The other options (housework, finances, and meal preparation) are typically classified as instrumental activities of daily living (IADLs), which reflect more complex community-living skills. Distinguishing ADLs from IADLs helps identify functional decline and the level of assistance or support services needed.

Question 28

The nurse is teaching a diabetic client how to monitor her blood glucose using a glucometer. The nurse will know the client is competent in performing her finger-stick when she?

Accepted Answer

Answer reason: The key principle is to obtain an adequate capillary sample while minimizing pain, tissue trauma, and interference with fine touch. The lateral side of the fingertip has fewer nerve endings and avoids the thick callused central pad, improving comfort and sample quality. Puncturing the finger pad increases pain and can promote callus formation over time. While site rotation and avoiding overly sensitive/functional digits can be helpful, the most universally correct technique indicator of proper finger-stick method is using the fingertip side.

Question 29

A nurse is instilling ear drops to a 7-month-old client diagnosed with acute otitis media. Which of the following techniques is appropriate?

Accepted Answer

Answer reason: For infants and children under about 3 years old, the external ear canal is shorter and angled upward, so the auricle is gently pulled down and back/outward to straighten the canal and allow the drops to reach the intended area. Pulling the pinna up and back is the technique used for older children and adults and can reduce medication delivery in an infant. Warming drops should be done by holding the bottle in the hands or placing it in warm water; microwaving risks overheating and burns. Cooling drops can provoke vertigo and discomfort and is not recommended.

Question 30

It refers to the preparation of the bed with a new set of linens?

Accepted Answer

Answer reason: The term that specifically names the act of changing/arranging linens and preparing the bed is bed making. A bed bath and bed shampoo are hygiene activities for the patient’s body or hair, not the bed itself. “Bed lining” is not the standard nursing term for this procedure in basic care terminology.

Question 31

The nurse is observing a staff member provide oral care for a client who is unconscious. The nurse should intervene if the staff member is observed?

Accepted Answer

Answer reason: Unconscious clients lack protective airway reflexes, so oral care must prioritize aspiration prevention through proper positioning. The head should be turned to the side (lateral position) with the bed slightly elevated as appropriate, allowing secretions and rinse solution to drain out of the mouth rather than toward the airway. Keeping the head in a neutral, supine alignment increases the risk that pooled fluids will flow posteriorly and be aspirated. The other actions are standard components of oral care for an unconscious client when performed gently and with suction available.

Question 32

Which of the following is the appropriate treatment for miliaria?

Accepted Answer

Answer reason: Reducing layers improves heat dissipation and decreases sweat retention, helping the rash resolve. Oily products can further occlude sweat ducts and worsen the condition. Soothing lotions may reduce itching but do not address the primary trigger unless combined with cooling and keeping the skin dry.

Question 33

A nurse is teaching a client with glaucoma the proper technique for instilling eye drops. The nurse would instruct the client to instill the drops?

Accepted Answer

Answer reason: Eye drops are placed into the conjunctival sac to maximize local absorption and minimize corneal irritation or injury. Pulling down the lower lid creates a pocket that holds the medication and reduces blinking-related loss of the drop. Instilling directly on the cornea can cause discomfort and reflex tearing, which can wash out the medication. Avoiding placement near the lacrimal duct also helps limit systemic absorption via nasolacrimal drainage, an important safety point with glaucoma medications.

Question 34

Which care plan goal statement is written appropriately?

Accepted Answer

Answer reason: Appropriately written care plan goals are client-centered, measurable, and time-limited. This statement focuses on the client’s behavior (bathing) rather than the nurse’s task, and it includes a clear timeframe (“by discharge”), making it evaluable. Options A and C are nurse-centered task statements, which belong in nursing interventions rather than goals. Option B is client-centered but lacks a measurable timeframe, so progress cannot be clearly evaluated.

Question 35

What is the most appropriate nursing diagnosis for a client with a reddened sacrum unrelieved by position change?

Accepted Answer

Answer reason: A “risk for” diagnosis is appropriate when skin is intact without current signs of breakdown; here there is already evidence of pressure-related injury. The priority nursing problem therefore focuses on the present alteration in the skin’s protective function. Options like sedentary lifestyle or noncompliance do not directly capture the immediate clinical issue of pressure-related skin breakdown.

Question 36

A nurse prepares a client for a shave biopsy of a skin lesion. What is the priority information for the nurse to include in the teaching plan?

Accepted Answer

Answer reason: Priority discharge teaching should address immediate post-procedure wound protection to reduce bleeding and infection risk, which is accomplished by proper dressing care (keeping it clean/dry, when/how to change it, and when to report drainage, redness, or increasing pain). A skin graft is not a routine expectation after a shave biopsy and would be inappropriate to emphasize preemptively. Sedation is generally not needed for a shave biopsy, so it is not the priority teaching point.

Question 37

The physician orders a wet-to-dry dressing for a client who has a pressure ulcer with infected, necrotic tissue. The nurse understands that the purpose of this dressing is?

Accepted Answer

Answer reason: Wet-to-dry dressings are a form of mechanical debridement: as the gauze dries, it adheres to devitalized tissue and exudate, which are removed when the dressing is pulled off. This is specifically useful when a pressure injury contains necrotic, infected material that needs to be removed to reduce bacterial burden and allow granulation. Keeping a wound moist is the goal of modern moist wound healing dressings (e.g., hydrocolloids/foams), not wet-to-dry once dried. This method can be painful and can remove viable tissue as well, so pain reduction is not the purpose.

Question 38

A client has developed oral ulcerations secondary to chemotherapy agents. What is the most appropriate nursing intervention?

Accepted Answer

Answer reason: Chemotherapy-related oral ulcerations (mucositis) require gentle, nontraumatic oral care to reduce pain, prevent bleeding, and lower infection risk. A soft-bristle toothbrush helps remove plaque and debris while minimizing tissue injury to fragile mucosa. This directly addresses the cause of discomfort and decreases the likelihood of secondary infection in an immunocompromised client. Hydrogen peroxide rinses can be irritating and may delay healing, and avoiding oral temperatures is more relevant to neutropenia precautions than treating ulcerations themselves.

Question 39

The nurse is teaching a client about penile hygiene. What is the most important information for the nurse to include?

Accepted Answer

Answer reason: Hygiene teaching emphasizes cleaning technique that reduces the risk of moving microorganisms toward the urethral meatus, which helps prevent irritation and infection. Cleaning in a direction that ends at the tip supports removing secretions and debris away from the body and toward the exit point where it can be rinsed off. Soap use can be individualized because some clients tolerate mild soap while others develop irritation, so it is not the most critical universal point. Advising to avoid foreskin retraction is unsafe teaching for most uncircumcised adults because gentle retraction (if retractable) is needed to clean and then the foreskin must be returned to prevent paraphimosis.

Question 40

To properly instill eardrops in a 28-year-old client with otitis externa, which method is correct?

Accepted Answer

Answer reason: This technique helps medication reach the inflamed tissues in otitis externa without pooling near the entrance. Pulling the pinna down and back is the method used for children under about 3 years due to different canal anatomy. The option about palpebral fissures pertains to eye care, not ear drop administration.

Question 41

A topical corticosteroid cream is prescribed for a child with eczema. The nurse should instruct the mother to apply the cream?

Accepted Answer

Answer reason: Topical corticosteroids for eczema should be used sparingly and only on involved skin to reduce local adverse effects (skin atrophy, striae) and systemic absorption, which is higher in children. A thin film provides the intended anti-inflammatory effect without unnecessarily increasing dose exposure. Spreading it over the entire body or applying a thick layer increases absorption risk without added benefit. Skin should generally be clean before application, and suspected infection requires assessment and may need antimicrobial therapy rather than simply applying steroid.

Question 42

The nurse is providing oral care to an unconscious client. What is the most important step in the care of this client?

Accepted Answer

Answer reason: An unconscious client has an impaired gag and cough reflex, so airway protection and aspiration prevention are the highest priorities during oral care. Side-lying positioning promotes drainage of secretions and oral fluids out of the mouth rather than toward the oropharynx, reducing the risk of aspiration and subsequent pneumonia. While hand hygiene is essential for infection prevention, it does not address the immediate life-threatening risk posed by pooled fluids in an unprotected airway. Brushing teeth and providing privacy are appropriate but are secondary to maintaining a safe airway during the procedure.

Question 43

The nurse is preparing to perform foot care on a client. Which client would most likely require a physician’s order to trim the toenails?

Accepted Answer

Answer reason: Diabetes increases risk for peripheral neuropathy and peripheral vascular disease, which reduces pain sensation and impairs wound healing. Toenail trimming can easily cause small cuts that may go unnoticed and progress to infection, ulceration, or even osteomyelitis in this population. For safety, nail care is commonly deferred to a provider order and/or performed by podiatry using specialized techniques. The other conditions listed do not inherently carry the same high risk for unrecognized injury and poor healing from routine nail trimming.

Question 44

The nurse is caring for an intubated client diagnosed with acquired immunodeficiency syndrome. What is the most important intervention by the nurse?

Accepted Answer

Answer reason: Intubation increases the risk of ventilator-associated pneumonia because bacteria rapidly colonize the mouth and oropharynx and can be aspirated around the tube cuff. Regular, thorough oral care is a high-impact nursing intervention that reduces oral bacterial load and protects fragile mucosa, which is especially important in immunocompromised clients such as those with AIDS. Lubricating lips improves comfort but does not meaningfully reduce infectious risk. Routine suctioning may be needed based on secretions, but it does not replace antiseptic oral hygiene as the primary prevention measure, and scheduled tube repositioning is not a standard prevention priority compared with consistent oral care.

Question 45

A client with genital herpes asks the nurse what comfort measure can be recommended. What is the best response by the nurse?

Accepted Answer

Answer reason: Reducing friction, heat, and moisture helps decrease pain and irritation from HSV vesicles/ulcers and supports healing. Loose, breathable cotton minimizes rubbing on lesions and improves airflow, which is a practical comfort measure. Topical products applied directly to lesions can worsen irritation or introduce contaminants, and hydrogen peroxide is cytotoxic to healing tissue and can delay re-epithelialization. Avoiding trauma to lesions is important, but the most direct, safe, and broadly recommended comfort intervention here is minimizing local irritation from clothing.

Question 46

Which area of client teaching should be stressed when the goal is preventing the development of phimosis in a 20-year-old uncircumcised client?

Accepted Answer

Answer reason: Teaching should emphasize gently retracting the foreskin as tolerated, cleansing the glans and inner foreskin with mild soap and water, then returning the foreskin to its normal position to reduce irritation and infection risk. Regular ejaculation does not prevent foreskin scarring, and testicular self-exam targets cancer screening rather than foreskin complications. Hand hygiene is important for general infection prevention but is less directly effective than consistent preputial hygiene in preventing the pathophysiologic process leading to phimosis.

Question 47

The nurse is caring for a 12-year-old child with a diagnosis of eczema. Which nursing intervention is appropriate for a child with eczema?

Accepted Answer

Answer reason: Tepid baths help clean the skin without exacerbating vasodilation and dryness, and immediate moisturizer use helps “seal in” moisture and restore the barrier. Antibiotics or antifungals are not routine unless there is clear evidence of secondary bacterial or fungal infection. Hot baths and vigorous drying strip natural oils and mechanically irritate skin, typically worsening pruritus and flare severity.

Question 48

A 3-year-old child is being discharged from the emergency department after receiving three sutures for a scalp laceration. The nurse determines discharge teaching was effective when the parents tell the nurse they will return for suture removal in?

Accepted Answer

Answer reason: Suture removal timing is based on location and expected wound tensile strength needed to prevent dehiscence while minimizing scarring and track marks. Scalp lacerations generally require a longer interval than facial wounds because of thicker tissue and ongoing tension from hair/scalp movement, making about a week or slightly longer appropriate. Returning too early increases the risk of the wound reopening and bleeding, especially in an active toddler. Waiting excessively long increases the risk of suture marks and makes removal more difficult as epithelialization occurs around the suture.

Question 49

A mother of a 6-month-old infant with atopic dermatitis asks the nurse for advice on bathing the child. What is the best response by the nurse?

Accepted Answer

Answer reason: Atopic dermatitis involves impaired skin barrier function, so minimizing excessive water exposure helps reduce transepidermal water loss and dryness that worsens pruritus and flares. Less frequent bathing paired with gentle cleansing helps avoid stripping lipids from the stratum corneum. Very frequent bathing can aggravate xerosis unless carefully managed with immediate emollient use. Bubble baths commonly contain fragrances and surfactants that can irritate eczematous skin and increase itching. Bathing practices matter in eczema management because they directly affect skin hydration and irritation.

Question 50

A client with cirrhosis is jaundiced and edematous. He’s experiencing severe itching and dryness and asks the nurse if anything can be done for his skin. What is the best intervention by the nurse?

Accepted Answer

Answer reason: Pruritus and xerosis in cirrhosis are worsened by dry, irritated skin, so the priority is gentle skin care that restores moisture and reduces irritation. An alcohol-free lotion hydrates without the stinging and drying effects that alcohol-based products can cause, helping decrease itching and risk of skin breakdown. Washing with soap and water can further strip oils and worsen dryness if used frequently or with harsh soap. Mitts may reduce scratching injury but do not address the underlying dryness driving the itching, making moisturizing the best first intervention.

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